Medical Education

Over on The Health Care Blog, Michael Painter, MD, JD, shares his thoughts from a recent meeting at Stanford’s medical school inviting medical education leaders to debate big questions in their field. Painter, a senior program officer at the Robert Wood Johnson Foundation, explained that meeting participants discussed ways that educators can use technology and other tools “to help create a durable culture of health for all.”

From the post:

In 2013 we extended a $312,000 grant to Stanford Medical School that will support work by five medical schools, Stanford, Duke, University of Washington, UCSF and University of Michigan, as they create a consensus knowledge map of the critical things medical students should learn.

Why a knowledge map? The simple answer: because there isn’t one, and we need one if we’re going to build massive core online medical education content.

Why change now? There’s building pressure on fortress academia: pressure to push health care toward high value, pressure for health care to center itself on the patient rather than the professional, and pressure from technology, specifically the ability to move previously closely held knowledge of the expert more efficiently to the learner.

Here’s where this mapping effort also starts to get interesting. It wouldn’t be that surprising if these education leaders ticked through all the reasons why change is too hard—why it can’t or won’t happen. Instead something marvelous is happening: they’re challenging each other to examine the time they spend with their students—asking if they ignite the kind of passion in their learners that others ignited in them.

An even more hopeful sign—these leaders want to connect the teaching of new healers—from the beginning—with the key partner: the patient. Their early reimagining is fixed on patient and story.

Previously: A closer look at using the “flipped classroom” model at the School of Medicine, Combining online learning and the Socratic method to reinvent medical school courses, Using the “flipped classroom” model to re-imagine medical education and Stanford professors propose re-imagining medical education with “lecture-less” classes

SMS (“Stanford Medical School”) Unplugged was recently launched as 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 category.

I had never seen my young cousin sit so still. “What did you do?” my aunt wondered, amazed that her hyperactive twelve-year-old had been transfixed for nearly an hour. “Were you two playing video games?”

“Actually we were just talking about some of the things I learned in medical school. He’s really interested,” I told her. Indeed, he hadn’t even touched one of the delicious samosas we were eating. Every time he picked one up, he thought of another question or exclaimed, “OMG. The body can do that?”

He wasn’t the only one getting excited. I had barely been in medical school for a few months, and was being exposed to the wonders of human biology on a daily basis. Whether beautiful or frightening, it was all fascinating – and like my cousin, my classmates and I consumed it with the voracity otherwise reserved for a savory samosa.

At the same time, we learned to comport ourselves appropriately in the presence of patients, to contain our enthusiasm when faced with exotic diseases. First with patient-actors and then hospitalized patients, we learned to treat patients as people instead of diagnoses, and to be empathic even while being enthralled. Upon starting clinical rotations two years later, though, it became increasingly difficult to do so.

On one of my first evenings on call, I was sent to see a patient with appendicitis. “It should be straightforward, a really textbook case,” said the resident. The case was indeed straight out of a textbook, but not from the chapter about the appendix. I found myself staring at a man nearly seven feet tall, with the characteristic hollowed-out chest, spidery fingers and long limbs of – “Yeah, Marfan’s Syndrome runs in the family,” he said. “Every doctor stares when they first see me.”

I tried to never repeat my mistake, but sometimes it’s hard not to stare for at least a moment. In fact, students are often asked to do exactly that as part of the physical exam. Take the physical exam rounds, when a faculty member takes students to see patients with findings appreciable by careful examination. Even when those rounds are lead by the most empathic physicians, it’s hard to ignore the fact that we are not contributing to the patient’s care and do not even know much of their story. Rather, we walk into their room only to palpate a spleen or see a Babinski sign.

Not staring isn’t easier to do even on surgical rotations with less face-to-face patient interaction. During one operation, a neurosurgeon used an endoscope to navigate the deep recesses of the brain. While gazing at the anatomy that even the best textbooks don’t show in such rich detail, I forgot to breathe and nearly passed out.

Continue Reading »

Today on MedCrunch, Stanford medical school alumna Stesha Doku, MD, examines how digital resources can enhance the traditional medical school curriculum to ” help health-care professionals succeed in their goals to deliver quality care.” Highlighting online learning sites such as PodMedics, which offers medical and surgical video tutorials, Doku writes:

What we gain from the growth of such applications and more general sites such as Khan Academy is that the physical classroom is becoming less relevant. It’s not so much a question of the classroom being not enough, but rather if the classroom is the correct place to deliver our learning materials in the first place. If so, are we delivering distilled and most importantly relevant information?

While we value those who are ‘smart’ in medicine, we must make more effort to value those who can translate their knowledge into improving outcomes and progressing our field. This may mean spending less time on acquiring knowledge that has no application. This may also require spending more time practicing application.

Previously: Social learning in a medical photo-sharing app for doctors, A closer look at using the “flipped classroom” model at the School of Medicine, Combining online learning and the Socratic method to reinvent medical school courses, Using the “flipped classroom” model to re-imagine medical education and Rethinking the “sage on stage” model in medical education
Photo by Stanford Ed Tech

Last Friday, small envelopes containing big news were handed out at the Li Ka Shing Center for Learning and Knowledge. During Match Day 2014, med students at Stanford and around the country learned where they would be paired to begin residency, and thus the next phase of their lives and careers. My colleague Tracie White was on the scene when Stanford students opened their letters. She reports:

The 81 students matched in 19 different disciplines in a total of 15 different states. California topped that list with 17 percent of all the graduating students.

…

Seventy percent of the 81 students matched with their first choice and 90 percent with one of their top three choices. At the top of the list for medical specialties was internal medicine, with 19 students. Pediatrics came in second, with nine students.”It was a long, painful process,” said Kevin Chi, his shaking hands holding the letter that told him he had matched in pediatrics at Stanford, his first choice. He hugged fellow student Tania Rezai, who had matched to a family medicine residency in Santa Rosa.

Kira and Erick Westbroeks, pictured above with their baby, will be moving to Baltimore; Erick Westbroek matched in neurosurgery at Johns Hopkins.

Previously: Matching into family medicine, Image of the Week: Match Day 2013, My parents don’t think I’m smart enough for family medicine: One medical student’s story, Match Day 2012 decides medical students’ next steps and A match made in heaven? Medical students await their fate
Photo of the Westbroeks by Norbert von der Groeben

Medical students at Stanford, and thousands more around the United States, will gather this morning at 9 AM Pacific time for the annual Match Day celebration. Students will join family, friends and faculty members as they nervously clutch white envelopes, which indicate where they’ve been “matched” for their residencies and play an important role in shaping their futures. We wish students at Stanford and around the country the best of luck!

Match Day, for those not familiar, is the annual event where students learn where they’ll spend the next four to seven years of their lives completing residencies. To determine the post-graduation assignments, the nonprofit organization National Resident Matching Program uses a computer algorithm that aligns the choices of the applicants with those of the residency program.

This morning, my colleague Tracie White will be joining students on the Stanford campus to capture the ceremony and excitement. Watch for her story later on Scope.

Previously: Matching into family medicine, Image of the Week: Match Day 2013, My parents don’t think I’m smart enough for family medicine: One medical student’s story, Match Day 2012 decides medical students’ next steps and A match made in heaven? Medical students await their fate
Photo by Norbert von der Groeben

Tomorrow, medical students across the country, including those at Stanford, will find out where they’ll be doing their residency. In anticipation of the exciting event, known as Match Day, we’re re-publishing an entry penned last year by then-medical student Raymond Tsai. His candid and moving post was one of our most popular of 2013 and garnered comments from across the world. For the record, Tsai matched in family medicine at UCLA Medical Center (.pdf).

***

I’m not sure why my parents were surprised when I told them that I was applying to go into family medicine. It seemed like a logical transition after spending six years working in public health and primary care before medical school, but from the perspective of Taiwanese immigrant parents, I couldn’t have made a more absurd career choice. I was confronted with comments such as, “Most people choose careers to make money – why aren’t you?” Even more jolting was when they asked, “Why are you throwing away years of hard work and accomplishments?” I was flabbergasted by the line of questioning, but they’re my parents, so I had to answer the fundamental question – why family medicine?

For me, the answer is simple: I went into medicine to improve the health of my community and our society, and when I think about the most pressing health issues facing our nation, it’s preventable lifestyle disease. According to the Centers for Disease Control and Prevention, more than 75 percent of our health-care costs and 7/10 of deaths stem from chronic diseases that are largely preventable.

As a medical profession, we’ve largely been unsuccessful at getting people to engage in healthy behaviors. Luckily that’s where family medicine doctors are uniquely positioned to succeed. For one, the family physician has the breadth of training to serve everyone in a community, and in doing so, can influence community behavior as a whole. This approach is vitally important since lifestyle choices are never made in the clinic; they’re made in communities based on social norms set by families and peers.

Second, as I’ve learned through my own journey of overcoming obesity by losing 40 pounds in the past year, so much of one’s ability to implement healthy lifestyles hinges on one’s sense of self-efficacy. Again, that’s where the family physician comes in. A family physician has the benefit of deep interpersonal relationships developed through continuity of care to more effectively cheerlead and coach a patient to success. If executed correctly, family medicine has the potential to succeed in promoting healthy lifestyles, improving community health, and actually preventing disease in ways we haven’t been able to before.

The potential for primary care to fix our society’s biggest health-care problem and to have a real impact on overall population health is why I’m choosing to go into this field. Increasingly, policy makers are turning towards primary care to fix a health-care system that’s becoming more expensive than we as a society can afford. As that happens, I want to be at the front lines leading the charge and developing impactful solutions.

When I told my parents this, their response was, “There are already a lot of smart people who trying to fix this problem and unable to find an answer – so what makes you think you can?” In essence, they don’t think I’m smart enough for family medicine. The problem that primary care has been charged to solve is so big that my parents don’t think I can do it.

Maybe my parents are right, but that won’t stop me from trying. Ignoring the issue doesn’t make it any less urgent. To communicate this to my parents, I responded with a Chinese proverb they taught me long ago, “Plugging up your ears so you don’t hear the fire alarm doesn’t mean there isn’t a fire.”

Previously: Matching into family medicine

SMS (“Stanford Medical School”) Unplugged was recently launched as 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 category.

In many ways, the first year of medical school feels just like undergrad to me: I spend much of each day in basic science classes, regularly meet with my academic advisor, work on problem sets with classmates, and try – as unsuccessfully as I did in college – to maintain a regular work-out schedule.

Of course, there are aspects to my first year that were not present in my undergrad years. Patient presentations are a familiar component of our classes, with our instructors bringing in a patient and their family, who in turn share their unique stories with us and give us the privilege of asking them questions about their conditions and their care. In addition, we spend two hours every Monday and Friday in the clinical skills component of our Practice of Medicine (POM) course, learning the core components of the patient interview and the physical exam.

Both patient presentations and POM sessions have been the highlights of my first year but neither experience has made me feel like a “real physician.” Yes, I’m drawn into patients’ hopes, struggles, and experiences during patient presentations, but it’s a faculty member with extensive clinical experience, not me, who guides the conversation. In POM, I appreciate the opportunity to practice with standardized patients (SPs) and classmates in a safe environment, but it feels very much like “playing doctor” because – let’s be honest – both the SPs and I know my medical knowledge is pretty limited at this point.

For some reason, it wasn’t until we learned the genitourinary exam that the reality of becoming a doctor began to sink in for me.

Continue Reading »

Inspired by NPR’s “This American Life,” as a Stanford med student Danica Lomeli, MD, started a podcast series to document and share the intense clinical experiences of her classmates. Through digital storytelling, she captured the growth and distress she saw among third-years and provided a space for her peers to reflect on profound personal experiences. Lomeli, MD, now in her first year of post-graduate work in family medicine at UCLA, hosted and produced five podcasts before collaborating on one installment with and then passing on her project on to med student Emily Lines, who uses the platform to share stories of pre-clerkship students. Lomeli and Lines have produced their podcasts under the guidance and support of Stanford’s Medical Scholars Research Program.

Below, Lines answers questions on her podcast series, Becoming Doctors: Stories From in Between.

Can you describe some of the stressors a medical student undergoes, or which challenges med school presents to a student’s sense of humanism and developing identity as a physician?

There is a growing body of work cataloguing the experiences of clerks, interns, and residents through their transformation into physicians, but little has been recorded about the lives of medical students prior to the clerkship years. These years, however, are a period of rapid growth and transition for pre-clerkship students, filled with experiences worthy of documentation. Pre-clerkship students live at the bottom of an extensive hierarchy and may tend to minimize their emotions or the intensity of their experiences when they compare themselves with all they have heard from clerkship students or residents. By giving voice to these trainees early in their careers, I hope to spark an early interest in reflective practice and empower students to see the intrigue in their daily experiences.

We all have a story of our first patient, the first death we see, the first big mistake we make, and the ways that our personal lives are forced to change to make space for dedication to medicine.

How do you decide on topics to cover, and your approach to a given subject?

I just keep my ears open all the time for stories my friends are telling. Sometimes I’ll approach folks and ask them to tell specific stories I’ve heard them tell before.  Other times, I host storytelling parties, which are just informal get-togethers at my house where people can come and share stories in a group setting. We set a microphone out and pass it around as we talk about whatever happens to come up. Most recently, I hosted a themed storytelling party where a group got together to talk about primary care – experiences, passions, motivations, anything! In short, it’s pretty free-form and I take a varied approach to getting stories – whatever method fits the style of the storyteller and his or her story.

Any dream interview subjects?

A lot of people my age don’t see themselves as having a story to tell, but I think that everyone has a great story to share. They are my dream subjects! I hope for my classmates to see the uniqueness of their experiences and to come share them with me.

What are your plans for after graduation? Will you continue to be involved in telling stories?

I’m a pretty gregarious person and I think I’ll always keep telling stories (recorded or not!) I see podcasting as just one way that people can tell their stories – we can write, share in the moment with our friends, take photos, or made podcasts. I am a longtime college radio music DJ and, for me, podcasting was an obvious arena where I could blend my life in medical school with my life at the radio station. I’ve also brought music into the podcast, tapping into the musicians in my class and their recordings, so it’s been great to continue working with music as I develop my storytelling and hosting skills.

Continue Reading »

SMS (“Stanford Medical School”) Unplugged was recently launched as 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 category.

When I picture my future career, I see myself more as a community physician with a foot in academia than as an academic physician with a habit of finding himself in the community. Working in a county hospital and being involved in community-health programs have always been desired and natural end goals for me.

In college, while fellow pre-meds sought out laboratory research and publication opportunities, I was most content teaching health-education workshops in public high schools. In medical school, while others worked in clinical science labs, I chose to work as a health navigator in a clinic. I value the concept of biomedical research and its contribution to medicine as we understand it, but I feel more at home in community outreach than I do in lab research.

Academic medicine has traditionally been centered on advancing clinical and physical sciences, and knowing this wasn’t an interest of mine, I began to see it as something  perhaps I shouldn’t be a part of. I worried that academic medicine might draw me away from community involvement and, worse yet, I met professionals who felt I should focus on academic medicine or community medicine, unconvinced that I can do both.

But yet, I also enjoyed the innovation, the cutting-edge practices, and the game-changing discoveries that come from academic medical centers. And I came to realize that academic and community medicine actually aren’t mutually exclusive – it’s just that the traditional definitions I have of them imply they are. Unfortunately these were the definitions I brought with me into medicine, a consequence of the misrepresentations that exist at the pre-med level.

It was the advisors, professors, and students who make up the Community Health scholarly concentration at Stanford, through their approach to medicine, that showed me a redefined possibility for academia in community health. Currently, as I work on my Masters of Public Health I’m also looking to redefine the potential roles I can take as a physician. And as medicine and public health continue to embrace a synergistic approach to caring for people, I’ve tried to adapt my view of what being an academic physician can mean. While I may not be meant for research dealing with pathogenesis of disease, biophysical properties of medications, or stem cell innovation, I envision my role in understanding and developing the practical delivery of medicine, studying health-care use patterns, impact of health education, and health-needs assessments on a community level.

Lloyd Minor, MD, recently wrote in his “Letter from the Dean” that, “On an institutional level, we are striving toward excellence in patient care by building a network of care that gets our specialists out into the community and brings high quality physicians from the community into Stanford Medicine.”

Validating my career goals, Dean Minor recognizes that community experience is as essential to complete health-care delivery as academic experience, and that we need to strive to create an exchange of skills and service between the two. Academic inquiry in the community setting is necessary to inform best practices and better serve the target population of health interventions. In turn, community experience is important in the academic setting to better inform policy and directionality of health-care changes to ensure the most vulnerable populations are not forgotten.

I don’t see myself in the traditional academic role, marked by research, publications, and tenure tracks, but more as a physician learning skills in the academic setting to use more directly in the community, serving groups that might otherwise not be exposed to health professionals with such training.

SMS (“Stanford Medical School”) Unplugged was recently launched as 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 category.

After my recent post about choosing to start a family while in school, a friend and student at another med school responded:

At least for me, another thing that comes into play is the debt load… I myself will be carrying a debt load akin to a mortgage by the time I graduate (not by choice; my tuition and fees alone work out to $55k/yr) and as someone who will most likely [be] in his mid 30s… before he starts making real money, this has really hit close to home.

Fair point. According to this nightmare-inspiring AAMC fact sheet (.pdf), the median graduating debt for U.S. med students is $175,000. That debt undoubtedly looms large in major career and life decisions such as specialty choice, where to live, and when to start a family.

Thankfully, my debt will be nowhere near that figure, and I’d like to share the reasons why. I hope this will encourage those of you applying to medical school to think broadly about factors that will impact your debt at each school on your list. When I began the application process I never would have guessed that Stanford, with a “sticker price” of $65K per year in tuition, would be my most affordable option.

Of course, everyone’s situation is different, and I can only speak from my own experience. However, it is telling that our average debt is consistently among the lowest in the country, despite our location in a region known for its sky-high cost of living.

So here’s a few of the reasons why my household of two med students and a baby will graduate with a very manageable debt burden:

1. A solid need-based financial aid package
The packages Stanford offered to my husband and me were comparable to those offered by peer institutions. That means tens of thousands in grants, plus loans that don’t accrue interest during training.

2. Teaching assistantships
The TA program is one of my favorite things about Stanford Med! The opportunity for students to teach is integrated into our curriculum and encouraged in a way that, as far as I know, doesn’t exist at any other school. We serve as very well-paid TAs (regardless of financial need) for both core preclinical courses and fun electives. As an aspiring educator, this is a dream come true. I develop my teaching skills, reinforce my knowledge of important material, get to know the students in the classes below me, and work with faculty mentors who are passionate about education – all while dramatically lowering my debt.

3. Med Scholars program
Med Scholars supports student scholarly projects (anything from working in a lab to writing a novel), by granting tuition support and a living stipend. Assuming we write a solid proposal, there’s enough funding for every student regardless of financial need, so we’re not left scrambling for scarce outside research funding.

4. Outside scholarships
My husband and I have both benefited from generous outside donors, to whom we are immensely grateful.

5. Never having to buy my lunch
In the preclinical years, rarely a day went by that I didn’t get free lunch (and sometimes dinner) through seminar series, elective courses, or student group meetings. During clinical rotations, the feast continued: Many departments have daily seminars with lunch provided. For the rare day when I don’t get fed, I can always pack my own simple but nutritious lunch for about $1.50. So there is really no reason to spend my student loan money on expensive cafeteria food.

6.“Odd jobs”
Our flexible school schedule gives me time to earn extra income through jobs like babysitting and tutoring.

7. Biking everywhere
Stanford and its surroundings are super bike-friendly, making me healthier, happier, and blissfully unaware of fluctuating gas prices.

8. Groceries from The Milk Pail Market
At this quirky little store within biking distance of campus, I can fill up my cart with enough veggies, fruits, beans, and grains to feed us for a week – all for less than $20. My medical advice is to skip their unpasteurized milk, though!