This blog is about medical education in the US and around the world. My interest is in education research and the process of medical education.

The lawyers have asked that I add a disclaimer that makes it clear that these are my personal opinions and do not represent any position of any University that I am affiliated with including the University of Kansas, the KU School of Medicine, Florida International University, or the FIU School of Medicine.

Monday, April 6, 2015

What I learned from a patient

Sorry for the long absence. This blog was written by one of my third year medical students. Please enjoy this reposting done with the student's permission...
The Herbert Wertheim College of Medicine (HWCOM) teaches its students to look beyond a patient’s set of symptoms. Social determinants – social and economic conditions that affect people’s lives and their health – must be taken into account as part of a plan of treatment. Third-year medical student Lisa Podolsky hopes to become a gynecologist/obstetrician. This is her account of a real-life lesson that illustrates why the World Health Organization deems “the social conditions in which people are born, live and work are the single most important determinant of one’s health status.”

By Lisa Podolsky 

Her story started pretty similarly to any other patient I’d had since starting my family medicine rotation. Once the nurse said she had another patient for me, I asked for the name and began looking up previous clinical notes and labs while waiting for her.

She had a history of arthritis, GERD and uncontrolled diabetes – all diagnoses I had become comfortable discussing with patients. Her last follow-up note indicated a plan to obtain x-rays for her knee pain; metformin [an oral diabetes medicine that helps control blood sugar levels] for her diabetes; and health maintenance screenings in the upcoming year.

Although I was confused why she did not have a visit in the previous nine months, I assumed she would have had an x-ray with some answers, and hopefully have lowered her glucose below the previous level of 400.

I was wrong.

The nurse escorted in a lady in gold shoes and a head-to-toe red outfit. As I waited for the nurse to finish taking her vitals, the lady in red began expressing her frustration at how long it took to get an appointment and her worries that her J02 card expired that day. A J02 card is a classification given out to Miami-Dade residents living 100 percent under the federal poverty level, providing them with hospital services without charge.

With her bag of Easter candies and soda in hand, she asked us to check her glucose level as she was concerned how high it had been at the last visit. I wondered why she was eating chocolate and drinking soda if she was concerned about her glucose level. I thought this would clearly be a visit filled with patient education about diabetes, glycemic index and healthier eating habits. As soon as the patient’s vitals were finished, the lady in red began reciting her problems to me: vaginal itching, acid reflux, “sugars”, loss of feeling in her hand, breast pain; the list went on.

When I started asking about each complaint individually, I could not understand how someone had gone unseen with so many symptoms, each of them unaddressed and having worsened in the past year. How could a patient have vaginal itching and discharge for more than a year? How could a patient feel pain and a lump in her breast without telling someone? How could someone with a previous glucose more than 400 stop her metformin? I remember asking her to remove her shoes to check for ulcers, and immediately the smell of the fungal infections in her toenails filled the room. However, with each complaint more of the story unraveled.

She was homeless and could no longer afford Nexium; water and baking soda would have to do for her reflux. If her sister needed to have her toes amputated because her diabetes was so bad, why wasn’t the patient more concerned about her own diet? The candy only cost 50 cents and her food stamps had run out. But why did she stop the metformin if it’s free from Publix? She lost her bus card and had no way to get to Publix.

With each part of the story, her depression became more evident. She tried to commit suicide two months ago, but was unsuccessful; she felt she even failed at dying. She didn’t understand why God kept letting her wake up each morning. Although I’d seen patients with depression most days since I started my rotation, I had never discussed previous suicide attempts. She was the second patient ever to cry to me. I had never seen such hopelessness, and it broke my heart.

Our approach had to change. We were no longer concerned about addressing her acid reflux, arthritis or health maintenance. Our priorities had to be about addressing the most imminent and extreme issues: her suicidal thoughts and diabetes. We had to mobilize the nurses and pharmacy in order to obtain her free metformin in the clinic that day, before the pharmacy closed and her JO2 coverage ran out, and before she fell to the risk of requiring amputation like her sister.

Next step, refer her to a psychiatrist – but that costs money. We discussed with her exactly how she could obtain a Jackson homeless card, so all referrals, tests and medications would be free, and we could see her again.

By the end of the visit, I felt I had just come out of a whirlwind tunnel. Although our assessment and plan at the end of the visit didn’t address everything we had hoped for at the beginning of the visit, I know we helped this patient.

From her, I learned to look beyond a patient’s medical problems, taking into account a person’s psychosocial problems as well. Treatment plans are not “one size fits all.” Understanding this patient’s depression and lack of resources were critical to providing the best possible care. Referrals for x-rays or discussing diet wouldn’t have mattered; she couldn’t afford x-rays and she ate what she could afford.

I learned how to better support an overwhelmed patient who felt hopeless, as well as how to ask for help from the nurses, pharmacist and finance department to address extreme situations. No matter the situation in life, you always have to be adaptable to change, listen for the subtle comments, and prioritize the patient first- as a whole person- not just as a list of medical problems. By listening to her talk about walking to the clinic, and about her missing her family, we were able to probe further into her depression.

Medicine is an ever-changing field, whether it’s the patients, guidelines, economics, medications, or scientific discoveries. Medicine requires knowing how to adapt to change by knowing the whole story, and then working with the resources available. On the seventh day of my family medicine clerkship, the lady in red helped teach me those lessons.

Monday, October 6, 2014

Be FAIR to students

I recently saw a great editorial in the Medical Teacher.  Medical Teacher is the official journal of AMEE, an international association for all involved with medical and healthcare professions education. The Medical Teacher “addresses the needs of teachers and administrators throughout the world involved in training for the health professions.” (1)

The editorial by Harden and Laidlaw (2) discussed the FAIR principles that teachers can use to help their students develop and that lead to better learning. As someone who works in faculty development for my department and my institution, I found these principles to be an effective faculty development tool. 

The four principles of FAIR are:

            F          provide appropriate Feedback to students
            A         make learning Active not passive
            I           Individualize learning
            R         ensure the learning is Relevant

Feedback is something that I have written about here in the past (see- Feedback or Compliments? Which is better?)  Feedback is important for learners. It helps students to get better by giving the teacher the opportunity to correct mistakes. Dr. Harden quotes a 2007 review by Hattie and Timperley. (3) The authors reviewed twelve large meta-analyses that included 196 studies that looked at feedback. They found that the average effect size of feedback on performance in several different contexts was about 0.79. For perspective, it was lower than the effect of direct instruction (0.93) but was greater than a student’s prior cognitive ability (0.71).  Not getting enough feedback is one of the most common complaints from medical students regarding their teachers. Feedback is “the most powerful single thing that teachers can do to enhance achievement of their students.” (1) An important point from this article is that is that students need to use feedback for it to be effective. Students should use feedback from the preceptors and faculty members to fix deficits through increased practice, readings, and experiences.

The second point is that learning needs to be active. Active learning has a lot of advantages for the learner—it keeps them engaged in the process, it allows them to interact with peers in small group peer teacher/learner activities, and it encourages learners to use electronic and other outside resources to enhance their knowledge acquisition. Dr. Harden makes the point that no matter what the context, learning activities should be “designed to be meaningful”. Often students feel that learning activities have no point. For some activities in medical education, I would have to agree.  

This leads into the third principle of FAIR which is that learning needs to be individualized. It is funny that Facebook, Twitter, and Google have figured this out in less than a decade while in medical education we still don’t do this. The model has remained for one hundred years, everyone gets the same curriculum taught in the same way with the same assessments at the end. There is data that suggests that students have different learning styles and benefit from individual attention to those

(reprinted from: Harden RM, Laidlaw JM. Med Teach. 2013; 35(1): 27-31)
styles (see my 2012 blog--Self Regulated Learning and Performance)  We get students into medical school from a wide variety of backgrounds and experiences, but pay little attention to these differences. Some students come from a science heavy background while others from a more liberal arts background. Some students may have been heavily involved in clinical medicine by volunteering in a free clinic while others have almost no clinical experience. More attention to these differences would maximize the students’ learning.

The final area of concern to help us be FAIR to students is relevance. This used to be a big deal in medical education. When I went to medical school, there was very little clinical education before the third year of medical school, it was all basic science. As a student you were just trying to get through that so that you could learn to be doctor later. Now as a faculty member who not only teaches in the basic science curriculum, but also directs a basic science module, I find it easier to provide the relevance. I think that we do a better job of using clinical cases and vignettes to frame basic science knowledge in the clinical context. In this setting of relevance, I believe student learning is enhanced.

I believe that the bottom-line suggestions from this article can be very helpful in structuring our teaching:

1) Recognize the importance of feedback
2) Assess the extent of active engagement of your students
3) Individually tailor the learning environment
4) Ensure the relevance of all learning activities

(2) Harden RM, Laidlaw JM. Be FAIR to students: four principles that lead to more effective learning. Med Teach. 2013; 35(1): 27-31

(3) Hattie J, Timperley H. 2007. The power of feedback. Review Educational Research. 2007; 77: 81–112.