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Medical Education, Medical Schools

Using “spaced repetition” and other learning strategies to better retain medical school knowledge

Using "spaced repetition" and other learning strategies to better retain medical school knowledge

8747269303_eb647f98e2_zMany have described the medical school experience as “drinking from a firehose” of knowledge. Over on the Wing of Zock, radiology resident Peter Wei, MD, and MD/PhD student Alex Chamessian explain how they leveraged psychological research to develop new study techniques and better retain information as medical students.

To break the cycle of learning and quickly forgetting, they began using a technique known as “spaced repetition,” where material is regularly reviewed according to set schedule. They write:

At first, a newly learned fact is reviewed often; as time goes on, and the memory becomes deeply ingrained, it diminishes. In that way, you only have to study each fact exactly when the program predicts you’re likely to forget it – an enormous time savings. While cramming can buy you some short-term learning, if you want to retain information from medical school into clinical practice, spaced repetition is the way to go.

So, with this knowledge in hand, we and some of our classmates started using free, open-source flashcard apps, such as Anki and Mnemnosyne, which incorporate spaced repetition. Our understanding of the psychological literature also taught us the best practices for studying, and what sorts of resources to use for each course.

We talked with our classmates, who adopted parts of this methodology for themselves and offered useful suggestions to streamline it further. Pretty soon our class was teaching these techniques to the incoming first years, and a year later, that class started reaching out to the new incoming first years. And sure enough, many of us did very well on the USMLE step exams and found that had a firm grasp of clinical knowledge once we hit the wards; our studying yielded much better results than we could have expected otherwise.

In an effort to help other medical students learn more efficiently, Wei and Chamessian wrote the book “Learning Medicine, an Evidence-Based Guide” detailing the spaced repetition method and other learning strategies.

At Stanford, educators developed a new online learning initiative to re-imagine medical education using the “flipped classroom” model. The Stanford Medicine Interactive Learning Initiatives aims to make better use of the fixed amount of educational time available to train doctors and help students learn more efficiently.

Previously: Using the “flipped classroom” model to bring medical education into the 21st century, Flip it up: How the flipped classroom boosts faculty interest in teaching and A closer look at using the “flipped classroom” model at the School of Medicine
Photo by EdTech Stanford University School of Medicine

Medical Education, Medical Schools, Stanford News

Passing the boards: Reassessing “Step 1 madness”

Passing the boards: Reassessing "Step 1 madness"

medical booksCharles Prober, MD, senior associate dean of medical education at Stanford, has long been concerned about the misuse of Step 1. The national standardized test, which must be passed in order to get a medical license, is also often used inappropriately, according to Prober, as a screening tool by residency programs.

But his concern about the test — dubbed “Step 1 madness” by some med students and the first of three required for medical licensure — extends even further to what he and others believe are the unnecessary and sometimes detrimental effects on both the education of medical students and their stress levels.

In a commentary published this week in the journal Academic Medicine, Prober and his co-authors — which includes the president of the National Board of Medical Examiners, the non-profit that develops and manages the test — issue a “plea to reassess” its role in residency selection. They write:

There is an increasingly pervasive practice of using the score, especially the Step
1 component, to screen applicants for residency. This is despite the fact that the test was not designed to be a primary determinant of the likelihood of success in residency… [I]t is disconcerting that the test preoccupies so much of our students attention with attendant substantial costs (in time and money) and mental and emotional anguish.

Prober and his colleagues go on to explain how students sequester themselves for four to nine weeks on average studying full-time for the day-long multiple-choice examination, which is usually taken sometime following their second year of medical school. The stress to pass the test, which is designed to test  “important concepts of the sciences basic to the practice of medicine,” is particularly high because students know a poor score may keep them from qualifying for the first step to get into a residency program — the interview:

Despite its intended purpose, many residency program directors continue to use applicants’ USMLE Step 1 scores as a sole or primary filter for selecting candidates to interview… In general, the more competitive the residency discipline (e.g. orthopedic surgery, radiation oncology, dermatology, ophthalmology, and otolaryngology,) the higher the Step 1 score needed to pass through the filter.

The authors express the opinion that it is “ill advised” to use the test for a purpose for which it was not developed, that the test is not a good predictor of who will do well in residency and that it is being misused for “convenience” as a easy to apply mechanism to reduce large applicant pools. Their solution isn’t to get rid of the test, which is still a valuable tool, but to create additional measurement tools of equally important skills for selection by residency programs.

“A more rational approach to selecting among residency applicants would give greater attention to other important qualities, such as clinical reasoning, patient care, professionalism, and ability to function as a member of a health
care team,” they conclude.

Previously: Using the flipped classroom model to bring medical education into the 21st-century and Student transitions in medicine: putting blinders on
Photo by jcalyst

Medical Education, Medical Schools, Palliative Care, Patient Care, SMS Unplugged

When Mr. Bailey passed away: A student’s story

When Mr. Bailey passed away: A student's story

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged categoryCertain details in this entry have been omitted or changed, and all names have been altered to protect the identity of those involved.

387521264_d1cd33d574_zBrief life update, since it’s been more than 3 months since I’ve last posted on SMS Unplugged:

  • I disappeared for most of April through the end of May to study for and take Step 1, which – for anyone who hasn’t heard of this test – is a pretty brutal, not to mention expensive (~$590!! One of many reasons why med students are poor), 8-hour exam that tests broad concepts of medicine (biochem, immunology, organ systems, etc.) and is widely heralded one of the most important tests for residency admission.
  • I started clerkships at the end of June, with my first clerkship being in internal medicine. The rest of this entry describes one of the most poignant experiences from my first month and a half on rotations.

It was just another call day, when all of a sudden, an overhead announcement rang through the ward: “Code Blue, respond to Room 281. Repeat – Code Blue, respond to Room 281.” Instantly, the atmosphere in our team room turned serious: We knew it was one of our patients, Mr. Bailey, there. As a group, we sprinted towards Room 281. Disorganized, panicked thoughts were running through my head – oh-my-god-what-happened-to-our-patient, thank-goodness-I’m-wearing-sneakers-and-scrubs-today-there’s-no-way-I-could-run-like-this-in-flats, oh-my-god-what-happened-to-our-patient, oh-my-god.

When we got to the room, there were at least 8 people there already, with more trickling in. Our patient was covered in wires, IV lines, a face mask for oxygen. My resident stepped up to the bed and began telling everyone else about our patient’s past medical history, what we were treating him for, how his clinical course had been. I stood in the back, with the single-minded goal of keeping out of everyone’s way. For the next several minutes, at least a dozen people worked to bring Mr. Bailey back to life – and when I left the room, they had succeeded.

I walked back to the team room in a bit of a haze, the relief beginning to course through me, mixed in with remaining vestiges of adrenaline. I had only met Mr. Bailey once before, as he was primarily being followed by another member of my team. From our daily morning rounds, however, I knew he was incredibly sick. We estimated that he only had a few months left. When I met him that one time, it was so clear to see that he was struggling, to breathe, to keep his state of mind. Still, I thought it would be months, not days before he passed away.

The morning after the code, I came into the hospital at the usual time, pre-rounded on my own patients, and headed back to the team room to prep my presentation and notes for rounds. As I walked back to the team room, I ran into another team member, who asked me, “Did you hear about Mr. Bailey?” “No,” I said. “He died last night.”

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Events, Medical Education, Medical Schools, Stanford News

Aspiring young doctors learn the ropes during Stanford summer program

Aspiring young doctors learn the ropes during Stanford summer program

CSI participants - 560

Deep in the basement laboratory of Stanford’s Falk Cardiovascular Research Center, 31 high-school and college students stood in awed silence as surgeon Paul Chang, MD, demonstrated on the room’s large screen how to dissect a pig’s heart. After a moment of watching him point out the valves, atria, ventricles and arteries of the organ, students excitedly grabbed the surgical tools in front of them and began their work.

“This is so cool,” exclaimed Daria Arzy, a student at Harvard-Westlake High School in Los Angeles. “I’m more of a hands-on person, so I really enjoy this kind of thing.”

Heart dissection is just one sliver of the Stanford Medicine Clinical Summer Internship, a new program by the Division of General Medical Disciplines that was designed to provide a diverse group of students with an up-close and personal look at the field of medicine.

Department of Medicine Chair Bob Harrington, MD, greeted the participants on their first day and encouraged them to enjoy their time on the Stanford campus. “This is an amazing place,” he shared. “I’m still excited to come to work each day.”

Throughout the course of the two-week program, students learned the foundations of patient care, including how to take a patient’s medical history and vital signs, how to perform a physical exam, and how to administer ultrasounds and injections; practiced surgical techniques; and heard from cardiologists, neurologists, and other experts. “We encountered so many different perspectives,” said Kathy Zhang, a premed student at Vanderbilt University. “It was wonderful to meet medical professionals from different backgrounds and career pursuits.”

The students also had the opportunity to travel to the roof of Stanford Hospital to tour the school’s 50-foot Life Flight helicopter and to visit Stanford’s Center for Immersive and Simulation-based Learning, where they learned how to manage and treat infectious diseases.

During a guest lecture, Chloe Chien, MD, a Stanford medical student graduate and the COO of Homemade, a social healthy cooking program, shared her journey from medical student to startup co-founder. “When I was training to become a surgeon, I suddenly realized that I wanted to help prevent and heal lifestyle diseases like obesity and diabetes,” she said. “So I spoke to patients with chronic diseases to better understand what they were going through.” Chien later engaged the students in a lively discussion about the barriers to healthy lifestyle change, and offered three principles for healthy living: “Cook your own food, listen to your body, and eat whole, natural ingredients.”

On the final day, program organizers handed out certificates and offered their closing remarks to the group: “6 hours in the Stanford anatomy lab, 20 injected oranges, and 31 dissected sheep brains and pig hearts. By any numerical measure, this week has been impressive,” said Program Manager Misty Mazzara. “But this week was never about numbers.  It was about bringing bright young students together to introduce them to the practice of medicine.” Eva Weinlander, MD, who co-organized the internship with Sarita Khemani, MD, agreed, adding: “We have been lucky to spend time with all of you. You’ve all been so enthusiastic, professional, and supportive of each other during this journey.”

As the ceremony came to a close, participants lingered in the auditorium — hugging, taking photos, and exchanging contact information. One student echoed the sentiments of many when she yelled: “Don’t worry everyone, I’m coming back next year!”

Lindsey Baker is the communications manager for Stanford’s Department of Medicine. More photos from the internship program can be found on this Flickr page.

Previously: What’s it like to be an internal medicine resident at Stanford?At Stanford Cardiovascular Institute’s annual retreat, a glimpse into the future of cardiovascular medicine and A look at one high-school student’s summer internship experience at Stanford
Photo by Lindsey Baker

Global Health, HIV/AIDS, Medical Education, Medical Schools, Stanford News

Stanford med student chronicles his experience working in rural Kenya

Stanford med student chronicles his experience working in rural Kenya

Hodgkinson and others in Kenya

Growing up in Kakamega, a rural county in western Kenya, medical technologies and services were extremely limited for Luqman Hodgkinson, PhD. Now a first-year Stanford medical student, Hodgkinson is spending the summer months back in his hometown conducting research and chronicling exciting new developments in medical education – the opening of the first medical school in the region.

With a population of nearly two million, Kakamega is the second largest county in Kenya behind only Nairobi. But with only 12 physician specialists, the vast majority of residents don’t have access to advanced care.

Earlier this year, Masinde Muliro University of Science and Technology (MMUST), a leading public university in Kenya, received authorization to become the very first medical school in Kakamega; it’s expected to enroll its first class of students this fall.

Hodgkinson has received a faculty position as an adjunct associate researcher at the new MMUST School of Medicine and will serve as the designated ambassador from MMUST to Stanford.

As Hodgkinson writes in his first blog entry en route to Kakamega, “Relationships are very important in medicine and this is also true for a medical school that is at the beginning of a bright future.”

His first research project in Kakamega focuses on the efficacy of community outreach programs designed to improve adherence to antiretroviral medications among adults with HIV/AIDS. Under the mentorship of Michele Barry, MD, FACP, senior associate dean for global health at Stanford, Hodgkinson is working with Emusanda Health Centre to evaluate the efficacy of these programs and demographic factors that may impact medication adherence.

He writes in his blog: “Medical research of all kinds is greatly needed in Kakamega to advance the health of the community, particularly in the area of HIV. In Kakamega County, the HIV prevalence is 5.6 percent. Addressing the local HIV pandemic is what inspired me many years ago to pursue medicine and now for the first time I am on my way to join this endeavor.”

Hodgkinson will be blogging from Kakamega throughout the summer, sharing updates from his research activities and collaborative opportunities for members of the Stanford community to get involved with the new MMUST School of Medicine. Follow along on the Center for Innovation in Global Health website.

Rachel Leslie is the communications officer at Stanford’s Center for Innovation in Global Health.

Photo – of (left to right) clinician Jorcelyne Makori, peer educator James Okwiri and Hodgkinson – courtesy of Hodgkinson

Medical Education, Medical Schools, Medicine and Society, Stanford News, Surgery

How two women from different worlds are changing the face of surgery

How two women from different worlds are changing the face of surgery

IMG_1038“I hope you’re not serious about doing something in medicine.”

These words are all too familiar to Annete Bongiwe Moyo, a senior medical student at the University of Zimbabwe College of Health Sciences in Harare, Zimbabwe, and a former Stanford visiting scholar. In Zimbabwe, where the proportion of men to women in medical school is roughly 3:1, women are encouraged to take up professions as teachers, artists, caregivers – not doctors. And for a woman thinking about becoming a surgeon, well, she might as well keep dreaming.

Though the odds were stacked against her, Moyo made the decision to become a doctor at a very young age. But it wasn’t until she met Stanford surgeon Sherry Wren, MD, that she started to believe that becoming a surgeon was a realistic goal.

The outlook for women in surgery in Zimbabwe is not terribly unlike that in the U.S. when Wren began her residency at Yale University almost 30 years ago. After receiving her medical degree from Loyola University, Wren became the first woman from the university to specialize in surgery. At that time, only 12 percent of surgical residents were women, and the number of women surgeons in the workforce was far less.

But Wren has never let her womanhood hold her back. In fact, her powerhouse personality, fearlessness and passion for her work are the very traits that define her. She has worked all over the world, applying her skill and resourcefulness to provide the best possible care, often with extremely limited resources in remote locations. In many of these places, Wren is often the first woman surgeon anyone has ever seen.

Shocked too was Moyo when Wren appeared on her surgery rotation at the University of Zimbabwe two years ago. Here’s how Moyo recalls their first encounter – one that would have a lasting impact:

[Wren] was a visiting professor in a grand rounds. Medical students are not usually invited to grand rounds, but that day, we were permitted to attend. When the presentation was done, she asked a question, and when she looked my way, she could tell I knew the answer. She called on me, but one of my professors said ‘Wait, she’s a third year student, she may not know what you’re talking about.’ But Prof. Wren insisted, and I answered correctly. So she asked another question, and I got it right. And then another, and I got it right again.

The mood had shifted in the room. No one expected a junior female medical student could be capable of such an eloquent response. No one had ever given her the chance.

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Medical Education, Medical Schools, Medicine and Society, Research, SMS Unplugged

Research in medical school: The need to align incentives with value (part 3)

Research in medical school: The need to align incentives with value (part 3)

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the SMS Unplugged category.

This is the final post in a three-part series on research in medical school. Parts one and two are available here.

confusion-311388_1280In my last two posts, I explored the research paradigm of American medical training. The takeaway was that research requirements may create inefficiencies that have a host of consequences, including an unnecessarily long training process, a potential physician shortage, and an underutilization of talent.

In this post, I’ll lay out a vision for a training process that can produce a more effective physician workforce. The role of a physician has changed over time, and the education system must evolve to keep up. I’ll consider three topics: what students should get out of medical training, how schools and residency programs can help them do it, and how the system at large can enable schools to make changes.

What should students get out of medical training?

First and foremost, medical training should produce doctors who have a strong understanding of human health and disease and have the clinical skills to translate that understanding into patient care. The goal should be to produce good clinicians – that’s what the vast majority of doctors will focus on in their careers.

With that said, I accept the premise that medical training is not exclusively about clinical skills. Physicians are bright, capable individuals, and are uniquely positioned to improve the health status of their patients by other means. Schools should empower their students to pursue those opportunities. For the reasons I discussed in my last post, medical schools have decided that the primary way to do that is through research.

Research is one way to push extraordinarily important advances in medicine, but it isn’t the only way. Doctors can also improve their patients’ health by taking on roles in community health, policy, entrepreneurship or management, among others. These involve many of the same skills and techniques as research, but medical trainees don’t get exposed to these opportunities. We should.

How can schools fulfill this mission?

So how can the education system make this happen? At some point, whether it is in college or medical school, students should be given the flexibility to explore multiple domains of medicine and health care. They should then be able to pick the one or two that fit their interests and pursue them in more depth. Many students will choose to do research, while others will select other specialties. If students explore these opportunities and decide that they would rather focus on being an excellent clinician, that should also be doable.

This would allow physicians to become more effective leaders and decision-makers in the health care system. The traditional training process treats medicine as a universe of clinical practice and research, but the physician workforce has unfulfilled potential across a spectrum of other fields.

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Events, Medical Education, Medical Schools, Science, Stanford News

Stanford Medicine grads urged to break out of comfort zone, use science to improve human health

Stanford Medicine grads urged to break out of comfort zone, use science to improve human health

On Saturday, 195 graduates of the School of Medicine sat under a large white tent on the Alumni Green pondering the next chapter in their medical training. Many of them hadn’t been sure if they would make it to this milestone and, for some, the future seemed uncertain. But the message from Lucy Shapiro, PhD, a recipient of the National Medal of Science, was clear, “Step out of your comfort zone and follow your intuition,” she said. “Don’t be afraid of taking chances. Ask, ‘How can I change what’s wrong?'”

Shapiro told the Class of 2015 how she spent years performing solitary work in the laboratory before she “launched a one-woman attack” to influence health policy and battle the growing threat of infectious disease on the global stage. My colleague Tracie White captures Shapiro’s powerful speech in a story today about the commencement ceremony:

Her attack began with taking any speaking engagement she could get to educate the public about antibiotic resistance; she walked the corridors of power in Washington, D.C., lobbying politicians about the dangers of emerging infectious diseases; and she used discoveries from her lab on the single-celled Caulobacter bacterium to develop new, effective disease-fighting drugs.

Her lab at Stanford made breakthroughs in understanding the genetic circuitry of simple cells, setting the stage for the development of new antibiotics. Shapiro told the audience that over the 25 years that she has worked at the School of Medicine, she has seen a major shift in the connection between those who conduct research in labs and those who care for patients in clinics.

“We have finally learned to talk to each other,” said Shapiro, a professor of developmental biology. “I’ve watched the convergence of basic research and clinical applications without the loss of curiosity-driven research in the lab or patient-focused care in the clinic.”

grads walkingShapiro went on to tell the audience that bridging the gap between the lab and the clinic “can make the world a better place.” Lloyd Minor, MD, dean of the School of Medicine, agreed with these sentiments and told graduates that there has never been a better time for connecting advances in basic research with breakthroughs in clinical care. “You are beginning your careers at an unprecedented time of opportunities for biomedical science and for human health,” he said.

The 2015 graduating class included 78 students who earned PhDs, 78 who earned medical degrees, and 39 who earned master’s degrees. Among them was Katharina Sophia Volz, the first-ever graduate of the Interdepartmental Program in Stem Cell Biology and Regenerative Medicine. “Everybody here is reaching for the stars. We can do the best work here of anywhere,” she said.

Previously: Stanford Medicine’s commencement, in pictures, Abraham Verghese urges Stanford grads to always remember the heritage and rituals of medicineStanford Medicine honors its newest graduatesNational Medal of Science winner Lucy Shapiro: “It’s the most exciting thing in the world to be a scientist” and Stanford’s Lucy Shapiro receives National Medal of Science
Photos by Norbert von der Groeben

Events, Medical Education, Medical Schools, Stanford News

Coming up: A big day for Stanford Medicine’s Class of 2015

Coming up: A big day for Stanford Medicine's      Class of 2015

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Tomorrow, Stanford Medicine’s graduating class will walk away from campus with a new title: Doctor!

The speaker for the medical school commencement will be Lucy Shapiro, PhD, whose unique worldview has revolutionized the understanding of the bacterial cell as an engineering paradigm and earned her the 2014 Pearl Meister Greengard Prize and the National Medal of Science in 2013. The diploma ceremony will be held on Saturday from 11 a.m. to 1 p.m. on Alumni Green in front of the Li Ka Shing Center for Learning and Knowledge.

All of us at Scope wish the very best for the new graduates.

Previously: Match Day at Stanford sizzles with successful matches & good cheer, Abraham Verghese urges Stanford grads to always remember the heritage and rituals of medicine and Stanford Medicine honors its newest graduates
Photo by Andrew

Medical Education, Medical Schools, Mental Health, Stanford News

A call to action to improve balance and reduce stress in the lives of resident physicians

A call to action to improve balance and reduce stress in the lives of resident physicians

4086639111_a7e7a56912_zIn November of 2010, those in Stanford’s general surgery training program experienced an indescribable loss when a recently graduated surgical resident, Greg Feldman, MD, committed suicide. His death wound up being a call to action that brought about the Balance in Life program at Stanford, according to program founder Ralph S. Greco, MD.

With the Balance in Life program now in its fourth year, Greco; chief surgical resident Arghavan Salles, MD, PhD; and general surgery resident Cara A. Liebert, MD, have learned much about the daily stresses that resident physicians face. In a recent published JAMA Surgery opinion piece they wrote:

As physicians, we spend a significant amount of time counseling our patients on how to live healthier lives. Ironically, as trainees and practicing physicians, we often do not prioritize our own physical and psychological health.

A recent national survey found that 40% of surgeons were burnt out and that 30% had symptoms of depression. Another study reported that 6% of surgeons experienced suicidal ideation in the preceding 12 months. Perhaps most startling, there are roughly 300 to 400 physicians who die by suicide per year—the equivalent of 3 medical school graduating classes.

Greco, Salles and Liebert explain that the Balance in Life program is specifically designed to help resident physicians cope with these stresses by addressing the well-being of their professional, physical, psychological and social lives. To accomplish this goal, the program offers mentorship and leadership training activities; dining and health-care options that are tailored to the residents’ busy schedules and needs; confidential meetings with an expert psychologist; and social events and outdoor activities that foster support among residents.

The authors concede that the program may not fix every stressful problem that their residents face, but it does let the residents know that their well-being is important and valued. “This may be the most profound, albeit intangible, contribution of Balance in Life,” the authors write.

Although the program (and the JAMA article) is geared for people in the medical field, it’s not much of a stretch to see how its core principles can apply to any work setting. Learning how to manage stress and reach out to colleagues for support is a valuable skill and, as the authors write, to provide expert care for others you must first take good care of yourself.

Previously: After work, a Stanford surgeon brings stones to lifeSurgeon offers his perspective on balancing life and workProgram for residents reflects “massive change” in surgeon mentality, New surgeons take time out for mental health and Helping those in academic medicine to both “work and live well”
Photo by Gabriel S. Delgado C.

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