Teaching is Love

 From the 1/29/2021 newsletter 

 

Teaching is Love

 

 

Megan Schultz, MD, MA 

 

 

Dr. Schultz, who taught Spanish in an urban Baltimore high school before going into medicine, shares the story of the student who inspired her to become a doctor …

 

 

Before I was a doctor, I was a teacher. I taught Spanish at Frederick Douglass High School in Baltimore for two years before I decided to go to medical school. It was one of my students, Torreantoe Smalls, who inspired me to become a doctor. Torry was mischievous, with a quick grin. He played the trumpet like nobody’s business and tried, sweetly and patiently, to teach my clueless, clumsy feet how to step dance. He once got a B+ on a Spanish exam, and even though he was just beside himself with pride, he made me swear up and down I wouldn’t tell anyone he had had actually studied for it. During his senior year, Torry was shot multiple times in the abdomen during an attempted robbery. He would ultimately spend two years and three months of his life in the hospital, enduring dozens of surgeries and losing nearly two feet of bowel. It was in his hospital room, staring at his small frame in the bed, surrounded by the clicks and beeps of machines, that I resolved to be a doctor. 

 

Fifteen years later, here I am: a doctor, yes, but also still a teacher. Instead of high school students, now I teach medical students, residents, and fellows. Instead of teaching people how to speak Spanish, now I teach people how to be doctors. This is a tall order; sometimes it’s hard to know what to prioritize. When I was in medical school myself, I often felt impatient and restless, like none of my professors really understood the point of being a doctor at all. They talked way too much about things like the Henderson-Hasselbach equationand not nearly enough about how to save the life of someone like Torry. And the way they taught! PowerPoint slide after PowerPoint slide, crammed with text in tiny font that I was expected to regurgitate on command. I have often thought that medical school would be far more interesting and effective if it were taught by good teachers who know nothing about medicine as opposed to good doctors who know nothing about teaching. But how to be a good teacher for medical trainees? How to balance the need for basic physiologic knowledge with broad themes of compassion and empathy? I decided to ask the person who inspired me to be a doctor in the first place: I decided to call Torry.

 

Torry is not Torry anymore; he is Mr. Smalls. He is now a teacher himself; he teaches percussion at Mervo High School in Baltimore. He is also father to three children and runs an entertainment company called TORKO ENT. He still has the mischievous grin – but the speed at which it appears has been tempered a bit by age and wisdom. I asked Torry what makes a good teacher. His answer was arrestingly simple: love.

 

Torry described the importance of love by telling me the story of Mr. Burton, his music teacher at Douglass High. Torry had met Mr. Burton when he auditioned for the Douglass Marching Band as a skinny 8^th grader – and from the beginning, Mr. Burton believed in him and acted like a father figure to him. “He was the first person to see who I really was,” Torry says. After he was shot, Mr. Burton regularly visited Torry in the hospital. One of the days Mr. Burton was visiting, he was asked to step out so the nurses could give Torry a bath. (For months, Torry could not move his legs, stand, or walk. As a result, he had to rely on nurses for sponge baths in bed, which he describes as a singularly humiliating experience. “You know, I’m cool, so I don’t want nobody giving me a sponge bath. But I didn’t have NO choice!” he says with that old grin.) 

 

Torry said, “This was when I knew Mr. Burton loved me as a son… After my [bath], after my visitors came back in, I was sitting there in bed trying to lotion myself. And I was so mad that I couldn’t move my legs, that I couldn’t reach my feet. The man took the lotion – I didn’t even ask him – he just saw me struggling.” And Mr. Burton knew what to do. The memory of Mr. Burton empathizing with him in that moment, selflessly helping Torry with such a basic need, still moves Torry to tears fifteen years later. “He made me feel that I was loved,” Torry says. 

 

To love our students – it’s not often something we talk about as teachers. But maybe it is love that’s the foundation of any successful student-teacher connection: to believe in our students, to know what to do when they are struggling, to help them without being asked. Maybe if we start from a place of compassion and empathy, all the basic physiologic knowledge will follow.

 

Without Torry, I don’t know if I would be a doctor today. I certainly wouldn’t be the same type of doctor. All my students in Baltimore taught me far more than I ever taught them – Torry is the perfect example of that. There is such beauty in knowing that he is a teacher now, seeing his students for who they really are, believing in them, loving them. Torreantoe Smalls: once my student, always my teacher. 

 

 

Megan L. Schultz, MD MA is an Assistant Professor of Pediatrics (Emergency Medicine) at MCW. 

 

Assessment of Communication Skills in Medical Education

From the 1/29/2021 newsletter

 

 

Assessment of Communication Skills in Medical Education

 

 

Mary Ann Gilligan, MD MPH

 

 

Dr. Gilligan, who has an interest in communication in medical settings, shares how she and colleagues are developing teaching methodologies and measurements of effective communication skills for medical students …

 

 

Expertise in communication skills is one of the essential components of clinical competence for doctors. Medical schools are required to include training in communication skills in their curricula. Historically, training has primarily occurred in the early years of medical school and the skills have not been consistently reinforced later in the clinical environment. Fortunately, we now have decades of research to help guide development of a successful program in communication skills training.

 

Assessment of communication skills is one key component of a successful program and is the focus of this article. However, in order to appreciate the role assessment plays, it is important to understand the other components. Core communication skills have been identified and models developed to facilitate teaching of the skills (e.g., Calgary-Cambridge, Three-Function, Smith). There is not one best model but, rather, each one has strengths and weaknesses. For a given program, it is important to choose a model on which to base the program that will provide a common language for both teaching and assessment of skills. There should be progressive building of skills across the curriculum, beginning with core skills in the early years with introduction of advanced skills (e.g., breaking bad news, motivational interviewing) in the later years when learners will be more likely have a chance to use them. The final component to a successful program is the “how” or methods used to teach: communication is a behavior and is best learned using active strategies with opportunities for practice and feedback.

 

 

Communication skills training at MCW

 

Improving communication skills training at MCW begins with changes in assessment, because assessment can drive curriculum change. A robust assessment program will provide the data needed to inform what and how communication skills are taught. Currently at MCW, one important method of assessment of communication skills has been the Objective Structured Clinical Examinations (OSCEs). In the last year, we used a validated communication skills checklist for M3s based on the Three-Function Model for the OSCEs with plans to expand usage to all OSCEs in the near future. Use of the checklist across all years of the curriculum will allow students to track their progress on skills over time. I have been working with Dr. Tavinder Ark and the Kern Institute Data Lab on expanding use of the checklist, analysis of data, and generation of reports for students. 

 

Assessment of communication skills on clinical rotations could serve as another important source of data on competence in communication skills but will require investment of time and effort, especially for faculty development.

 

We are on our way to developing a program that achieves the goals of assessment in medical education as defined by Kalet and Pusic: 1) to motivate and guide [learners] to continually aspire to higher levels of expertise, 2) to identify [learners] who are not competent to practice safely, and 3) to provide evidence that the [learner] is ready for…unsupervised practice.

 

 

For further reading: 

 

Kalet A, Pusic M. Defining and assessing competence. In Remediation in Medical Education: A Mid-Course Correction, Kalet and Chou, eds. Springer. 2014.

 

 

 

Mary Ann Gilligan, MD MPH is a Professor in the Department of Medicine (General Internal Medicine) at MCW. She is a member of the Curriculum and Faculty Pillars of the Robert D. and Patricia E. Kern Foundation for the Transformation of Medical Education. 

Beyond Competency: Setting a Path to [Diagnostic] Expertise

 From the. 1/22/2021 newsletter

Perspective/Opinion

 

 

Beyond Competency: Setting a Path to [Diagnostic] Expertise

 

 

By Jayshil Patel, MD and Paul Bergl, MD

 

 

Drs. Patel and Bergl, who have a keen interest in “how doctors think,” discuss their curriculum to improve clinical reasoning skills …

 

Think about the last time you or someone you know went to a doctor with a symptom.  What did you or they seek?  Did you want an explanation for the symptom?  Did you want an efficient, yet thoughtful evaluation in arriving at a diagnosis?

 

Accurate and timely diagnosis is the foundation of medicine.  With it, management strategies have the best potential to positively modify disease and outcome.  Without accurate diagnoses, however, management is unguided and both potentially wasteful and ineffective. Thus, we advocate for undergraduate and graduate medical education to invest in setting learners on a path towards diagnostic expertise. 

 

Expertise does not stem from a superior natural capacity to analyze new information.  Rather, expertise is an adaptation, rooted in the ability to efficiently recognize patterns and compare it to what has been accrued in an individual’s extensive knowledge domain in their long-term memory.  Expertise requires deliberate practice, a concept coined by psychologist Anders Ericsson to describe the modus operandi of expert development.  Deliberate practice requires systematic and forced attention for refining performance.  Experts set a stretch goal, deconstruct its components, and hone narrow aspects of their performance until achieving mastery. 

 

 

Deconstructing the “diagnostic process”

 

Fortunately, the diagnostic process can be deconstructed, and its steps deliberately practiced, thereby allowing the practitioner to remain on a pathway to diagnostic expertise. Unlike chess, music, or individual sports, however, measuring expertise in medicine is challenging.  Yet if we assume that consistency, efficiency, tolerance for uncertainty and ambiguity, and adaptability are key features to any form of expertise, then enhancing diagnostic performance would be aided by a rich understanding of the diagnostic process and mastery of its components.  With systematic and forced attention towards elements of the diagnostic process, knowledge (within the limits of working memory) becomes amenable to processing and reorganization into more meaningful units called “chunks.”  

 

When new information arises, the working memory rearranges its components into a coherent cognitive representation by connecting and cross-referencing this emerging knowledge with established “chunks” of information already stored in long-term memory, ready for rapid retrieval into working memory.  Not only do expert diagnosticians possess extensive knowledge, but through deliberate practice, they store this knowledge in well-organized schemata in the rapidly accessible long-term memory.   

 

Consider the alternatives and consequences to deliberate practice.  Learners (or practicing clinicians) may “practice” medicine by logging thousands of hours seeing patients; however, without explicit knowledge of the diagnostic process or well-defined goals for the steps of that process, they are at risk of repeating habitual tasks and on the pathway towards arrested development.  Without coaching or reflection, unguided learners (or practitioners) may not recognize failures, and they may default to an intuitive mode of thinking, which when overutilized, is a key driver of diagnostic error. 

 

 

The mechanics of a diagnostic reasoning curriculum

 

Diagnostic reasoning curriculum ought to change learners’ attitudes of their growth potential, build knowledge around the language and science of reasoning, and enhance specific skills through deliberate practice and reflection.  Implementing deliberate practice across the training spectrum requires a fundamental shift in how we teach diagnostic reasoning in today’s complex clinical learning environment.  Learners may perceive diagnostic reasoning as an intimidating black box and expertise as unattainable.  For attitudinal change, we suggest explicitly defining and calling out the stretch goal, namely, to create expert diagnosticians.  

 

Changing language to include phrases like “expert development” and illuminating a deconstructed pathway to expertise may foster a growth mindset, one in which learners peer into the black box of diagnostic expertise and gain intimate access to its many inputs and outputs.  We suggest a vision for medicine training be to gain the foundational diagnostic knowledge and skills to independently care for patients while deliberately practicing them toward expertise.

 

To build knowledge, the stretch goal should be deconstructed into discreet, teachable components.  In our curriculum, we have deconstructed diagnostic reasoning into: 

 

[a] the semantics of the diagnostic process

[b] the science of thinking, learning, and decision-making

[c] mechanisms for reflecting and strategies which may enhance diagnostic accuracy

 

Before applying their knowledge, experts in non-medical fields like chess, tennis, and art learn and master a common language.  Likewise, before applying medical knowledge, students master the language where words like dorsum, ipsilateral, and morbilliform codify concepts we all understand.  Similarly, the steps and scientific concepts of diagnostic reasoning include well-defined terms like problem representation, illness script, diagnostic schema, dual process theory, and cognitive load.  We suggest educators and learners first master the language of clinical reasoning.  Without this language, we create competency scales that deem trainees ready for unsupervised practice if they merely “synthesize data to generate a prioritized differential diagnosis and problem list.”  Oblique references to diagnostic reasoning are confusing.  Furthermore, without a shared dialect, we cannot apply diagnostic reasoning knowledge nor expect learners to reflect or teachers to coach.

 

Next, teaching the science of thinking is crucial to optimize reflection, feedback, and clinical decision making.  In our curriculum, we differentiate normative from descriptive modes of decision-making by illustrating Bayesian principles and outlining System 1 and 2 thinking, respectively, using medical and non-medical examples.  Describing concepts like cognitive load and cognitive bias may enable trainees to recognize methods to optimize learning and limitations of human thinking, respectively.  Furthermore, the advantages and disadvantages to various types of reasoning can increase self-awareness and consciousness of the mode employed, empowering trainees to better calibrate their own thinking over time.  Faculty development in the science of thinking and learning may promote their ability to, for example, recognize a scenario where learners (or their teachers) may be experiencing high cognitive load, to then take the steps to minimize it by enhancing the clinical learning environment.

 

Explicitly granulating components of the diagnostic process provides targets for feedback and self-reflection.  For example, accessing and selecting illness scripts are steps in making a diagnosis.  Illness script components include epidemiology, pathophysiology, symptoms and signs, diagnostics, and response to treatment.  Our (unpublished) research shows almost all novice learners recall signs and symptoms of disease but often lack working epidemiological knowledge or pathophysiologic insults.

 

 

A clinical example

 

Consider a situation where a novice learner working in an intensive care unit identifies a patient with new thrombocytopenia.  The learner mentions the patient was receiving heparin and orders tests to evaluate for heparin-induced thrombocytopenia without mentioning its epidemiology or considering alternative etiologies.  Two days later, the patient was found to have disseminated intravascular coagulation.  During a feedback session, one form of feedback might be: “Read more about thrombocytopenia.” 

 

But, if the community of learners and educators speak a common language around diagnostic reasoning and understanding the science of thinking and learning, feedback may be transformed from a nebulous, “Read more about thrombocytopenia,” to  “I’d like you to work on the epidemiologic component of your illness script for heparin-induced thrombocytopenia and develop a pathophysiology-based diagnostic schema for thrombocytopenia.”  

 

 

Feedback tethered by the language and science of the diagnostic process has numerous benefits.  By delineating components of the diagnostic process, educators and learners can better assess diagnostic performance through targeted feedback, and in turn, deliberately practice towards, in this example, enriching an illness script.  From the perspective of an educator, awareness of what constitutes an illness script led to recognition of an incomplete script (lacking epidemiologic knowledge for heparin-induced thrombocytopenia).  By having knowledge of “how we think,” educators and learners can have a conversation to metacognate and identify cognitive bias leading to potential diagnostic error.  

 

In our example, the learner did not consider alternative etiologies for thrombocytopenia and anchored onto a diagnosis of heparin-induced thrombocytopenia.  As a result, educators construct remediation plans.  The learner was advised to develop a schema for thrombocytopenia (i.e., form a systematic approach to a clinical problem).  Consequently, longitudinal follow-up is established.  

 

On subsequent interactions, the educator can assess if the learner, indeed, developed a schema for thrombocytopenia. From the perspective a learner, such targeted feedback is constructive and actionable and serves as both a tool and a metric, in this case, to enrich the heparin-induced thrombocytopenia illness script and deliberately practice thrombocytopenia schema formation.  Importantly, the learner has a framework to self-reflect on how, why, and which cognitive bias(es) was invoked. 

 

 

Opportunities for incorporating clinical reasoning education into the clinical learning environment

 

To enhance reflection, skills, and reinforce effective habits for expertise, we suggest creatively infusing opportunities to deliberately practice components of the diagnostic process into our fast-paced, complex clinical environments that are fraught with actual or perceived barriers, like hand off medicine.  We advocate for dedicated undergraduate and graduate medical education didactic sessions that teach the language and science of diagnostic reasoning.  Morning report, morbidity and mortality conference, and clinical-pathologic correlation conferences could serve as ideal venues to deliberately practice diagnostic reasoning concepts and reap the benefits of crowdsourcing.  

 

As we have observed in our curriculum, infusing the language of clinical reasoning in one venue will invariably lead to utilization in other venues.  On the wards, when housestaff hand-off their patients, the face-to-face handoff period is an opportunity for a second opinion for the person giving the hand-off.  For the individual receiving it, it serves as an opportunity to practice diagnostic reasoning components, including refining problem representation as new data trickles in before rounds.  During rounds, we propose asking learners for why and how a diagnosis was ascertained, as opposed to just what. 

 

Democratizing rounds and asking all learners, not just the one presenting, promotes group discussion and creates a clinical learning environment where all learners can be empowered to think aloud.  For educators, asking learners to reason aloud promotes active reflection and generates opportunities for coaching and critical appraisal of their diagnostic reasoning.  Ideally, coaching would be longitudinal and intensive but, as demonstrated above, focused feedback need not be laborious.  Embedding problem representations followed by a reasoned diagnostic conclusion into electronic notes promotes script selection and real-time visualization of missing components, schema formation, and a tool for reflection since the diagnostic process is often evolutionary.  

 

 

The end game

 

The objectives for medical trainees are to “practice” good medicine and become lifelong learners, sentiments captured in a revered Oslerian axiom: “The art of the practice of medicine is to be learned only by experience; ‘tis not an inheritance; it cannot be revealed… Know that by practice alone you can become expert.”  Explicit in this epigraph is the need for experience.  Implicit, but especially relevant today, is the need for aspiring expert diagnosticians to deliberatelypractice the components of diagnostic reasoning.  Otherwise, carrying forward today’s practice habits creates a cadre of experienced but overconfident non-experts – a perfect recipe for stagnation, repeated errors, and adverse patient outcomes.

 

 

 

 

Jayshil Patel, MD is an Associate Professor of Medicine (Pulmonary, Critical Care and Sleep Medicine) at MCW. He is a member of the Curriculum Pillar in the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

 

Paul Bergl, MD is an Assistant Professor of Medicine (Pulmonary, Critical Care and Sleep Medicine) at MCW.

 

 

Can the Observation of Art Make us Better Clinicians?

From the 1/29/2021 newsletter 

Perspective/Opinion

 

 

Can the Observation of Art Make us Better Clinicians?

 

 

By Stephen Humphrey, MD, Valerie Carlberg, MD, Alexandria Bear, MD, and Arthur Derse, MD, JD

 

 

Drs. Humphrey, Carlberg, Bear, and Derse describe how teaching Visual Thinking Strategies can improve perspective, communication, and empathy …

 

 

When people think of medical education, they envision the sciences – biology, pharmacology, physiology, and anatomy – among others. Artistry, or the consideration of art, is typically not deemed relevant to the skills a physician must acquire.  Despite this, many trainees have heard the adage “medicine is an art.” This phrase typically arises after a nuanced physical exam finding, an innocuous but relevant comment in a patient history, or the success of a forgotten treatment modality for a recalcitrant condition. The term “art” in that context means the application of knowledge, skills, and judgment. The Oxford Dictionary also defines, “art,” however, as “the expression or application of human creative skill and imagination, typically in a visual form such as painting or sculpture.” If we agree that medicine is both a science and an art, can observation of art make us better physicians?

 

In fact, research shows the study of art in medical education improves visual literacy, diagnostic accuracy, communication, self-reflection, tolerance for ambiguity, and builds empathy. Visual Thinking Strategies (VTS) is a teaching method based on the research of psychologist, Abigail Housen, and museum educator, Philip Yenawine, that has been effectively integrated into the curriculum at several medical schools. 

 

 

Visual Thinking Strategies – Questions

 

VTS is a method of art observation in which students are presented with a piece of art and VTS facilitators utilize three sequential, open-ended questions: 

 

“What’s going on in this picture?”

“What do you see that makes you say that?”

“What more can we find?” 

 

The questions guide students’ critical thinking. Skills derived from VTS can be applied to diverse scenarios, including the physical examination as well as discussions with patients or colleagues. At institutions utilizing VTS, it is incorporated into elective or mandatory courses for medical students in all phases of training. Usually, the VTS curriculum is a longitudinal experience over the course of a month or months. Though less common, some studies show benefit from a solitary experience or the ability to integrate VTS over several years.

 

 

A collaboration between MCW and the Milwaukee Art Museum

 

During the 2019-2020 academic year, Drs. Valerie Carlberg, Alexandria Bear, and Stephen Humphrey introduced VTS at the Medical College of Wisconsin. Their project, entitled “The Art of Observation,” was supported by the Kern Institute’s Transformational Ideas Initiative (TI²) grant mentored by Dr. Arthur Derse, in a collaboration with the Milwaukee Art Museum. 

 

The first session was implemented as part of the “Art of Medicine Through the Humanities” elective directed by Dr. Derse. Fifteen fourth-year medical students participated. Students observed art and clinical images and recorded their observations. Pre- and post-session surveys were distributed and the quality and quantity of their responses was evaluated in a blinded fashion. Not surprisingly, the session led to a substantial increase in the number of observations and descriptors. Students reported that the session was valuable, citing that it enhanced their ability to analyze images critically, articulate observations, and understand multiple perspectives. We look forward to hosting more sessions post-COVID-19.

 

 

Opportunities

Within the last year, VTS has been described and celebrated in the AAMC’s Report on The Fundamental Role of the Arts and Humanities in Medical Education (FRAHME) (AAMC, 2020). In the future, we envision The Art of Observation taking place over three to six sessions with roughly ten to thirty students each. This would include an introduction to VTS followed by sessions evaluating portraits, landscapes, and abstract art. Expanded techniques would include the evaluation of medical photographs, “back-to-back” drawing, and asking students to serve as facilitators. We might later include residents, fellows, and faculty members, advancing the Kern Institute’s goals of character, competence, and caring. 

 

 

The carryover into clinical medicine

 

By sharing observations aloud, participants will build confidence in diagnostic reasoning. Through listening and paraphrasing others’ observations, students will develop appreciation for diverse perspectives and increased tolerance for situations where there is no clear answer. Additionally, students will self-reflect and evaluate their assumptions, values, bias, and stigma, thereby building cultural competency, social intelligence, and caring. 

 

At a time of great challenge throughout the world, The Art of Observation and VTS can empower physicians-in-training at MCW to embrace whatever situations arise with improved perspective, communication, and empathy.   

 

 

Drs. Humphrey and Carlberg are Assistant Professors of Dermatology (Pediatrics) at MCW.

 

Dr. Bear is Assistant Professor of Medicine (Hospice and Palliative Medicine) at MCW.

 

Dr. Derse is Professor and Director of the Center for Bioethics and Medical Humanities (Institute for Health and Equity), and a faculty member of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.