Sunday, October 23, 2005

Circular Reform II

The meat.
The Poobah feeds us what he thinks good curricular reform looks like. We need to get away from spoon-feeding lecture material and move toward problem based learning. We neeed to encourage life-long learning. We need to promote horizontal and vertical integration, i.e. I need to talk to more 4th years. We need to get away from the 2+2 formula of medical education where there are two years of preclinical class-work and two years of clinical apprenticeship in the hospital. We should replace it with a 2x2 formula that promotes more integration between the preclinical and clinical worlds. I wonder if he's aware that, on a stricly mathematical level, 2x2 = 2+2? Obviously, this is deeper than math. Of course, I have no idea how 2x2 might work, and Poobah gives no pointers.

Poobah also encourages our initiative to promote good teaching and our huge push for professionalism. Little does he know that our professionalism teaching actually includes (see Hubris). Finally, he says that we shouldn't be seduced by false outcomes, things like standardized exam (board) scores, student satisfaction, and residency results (the Match). After all, we're amazing students, so we should do well on the boards regardless.

He talks about the need for humanism and the goodness of having a standardized patient interview as part of the 2nd step of the boards. He talks about the possibility of changing pre-medical requirements to start out with better trained students, or other larger reforms. In response to questions, he complained about the loss of low-income students who don't understand that they'll be able to pay their way out of the enormouse debt burden that medical school entails, and speculates unproductively about how medical schools can decrease their costs.


1. There's no data. I complained about this on the way out, and another student said, "There is data, he just didn't show it to us. If he had, it would have taken six hours." Maybe, but without the data, the hour speech is a waste of time. As Poobah said, one of the major obstacles to curriculum reform is student opposition.

2. I have very little to say to a fourth year, thank you very much. I mean, we can talk, but when we do I don't learn things that I need to know. Unlike undergraduate, there's not stuff that you need to start right now or you'll be screwed, because all that stuff is built into the curriculum.

3. 2+2 is not on the table. Sure, the inspiration for this system (The Flexner Report) is almost 100, but that doesn't automatically make it wrong. More significantly, the dean's office told the MSTPs that this is unlikely to change. Since we do 2+4+2, a major disruption of the 2+2 system will affect us deeply. This isn't to say that they would never do anything to inconvenience us, but they gave no details on what the reform would be, other than to say 2+2 was unlikely to change, which makes me feel more confident that it will be protected.

4. The reason DMS couldn't tell us what the reforms would be is that they pitched them as being student originated and student driven, so I resent the possible implication of this meeting that reform will be centrally designed and executed.

5. Problem based learning is not a panacea. For the non-medical types, PBL is a system where, rather than sitting in lecture, students are put in small groups and assigned problems to deal with. In medicine, these normally take the form of cases. The varied parts of the case serve as teachable moments, e.g. we have a patient with poor circulation and use it as an excuse to talk about hemoglobin. At the same time, we can talk about the physiology of circulation, how to interview this patient, what parts of the history are significant, how to deal with this patient's access to care etc. etc.

This sounds great, right? Kind of. This environment isn't the best environment for everyone. Some people love lecture (I go back and forth). If you don't learn from lecture, you just don't show up. If you don't learn from small group, they still take attendance, so you get to suffer through however many hours of groupthink, then go home and try to learn it your way. Regardless, some things are just better lectured. The tie-ins can be somewhat contrived. Each small group has to be led by someone, who will either be a professor (expensive) or a TA (useless). There's also no way to standardize what a small group will cover. Do you want to be treated by someone whose group shortchanged the hemoglobin, or the history taking? What happens when they have a patient that isn't a case? There are thousands of pathogens and drugs that 2nd years have to know cold - how is that case-able? Switching to case-based learning would also require Dupont to build us a huge new expensive building to accomodate the numerous small groups, making the transition that much more expensive.

Every generation has its own educational fads. Whole language. Integrated Math. International Baccalaureate. Self Esteem (ugggh). How do we know that PBL is a real advance and not a random gyration or cul-de-sac of edu-bureaucra-somethingorother?

6. My last question is not solely rhetorical. How do assess whether a pedagogy works? It's not trivial. One way is to look at internal grades. Early in Harvard's New Pathway program, for instance, rather than teaching students the names, origins, insertions, and actions of the muscles, they just taught them that muscles have names, origins, insertions, and actions. These students were quite noticeable in their 3rd and 4th years as they were the ones that had no f'ing idea what they were doing. We don't really have internal grades, so this won't work too well.

Since medical school involves a lot of material, one simple and obvious way to test multiple pedagogies is a standardised test, like the US Medical Lisencing Exam, and see whether a pedagogy improves scores. But Poobah said that board scores don't matter because we're such stellar students that we'd do well anyway. No. Look at Baylor. They teach to the boards to an outrageous degree, and their board scores are significantly higher than say, ours, since we basically ignore said boards. Thus, pedagogy can have an impact on board scores. Second, it's ridiculous for a person that is (somewhat) involved in running the USMLE to say that it doesn't measure anything. Emphasize touchy-feely all you like, but there is a body of knowledge that doctors MUST posses. The degree to which a school imparts that information is relevant, even if it is not the whole story.

MBA programs are ranked by how much money their graduates make after 3 years. The analogous system for medical schools would see where people go for their residency. This seems more reasonable than board scores - the application process involves interviews, recommendation letters and descriptions of our performance in clinical clerkships. If I've learned nothing, continued my unprofessionality, and turned into a peronality-free robot, they'll notice. There are problems with this, obviously. It's less quantifiable than boards, unless you want to assign points based on how prestigious the specialty and location of the residency are, which would itself be arbitrary. Since residency is a matter of matching, in which students rank their preferences, you could see what percentage of students get their first choice, but what if I rank a place first because I know they're the only place that will take me? Finally, part of the reason I'll get into a specific residency is because I went to Dupont. The system is sticky - difficult to change. Still, looking at the change in our performance, relative to ourselves, provides some quick feedback.

One could argue that the true definition for success lies in the future, some 10 years hence, when they see what kind of doctors we are. This is horribly non-quantifiable. How are they going to assess our competence then if they admit it's impossible to measure competence now? Is it going to be outcomes, in that our school is better if we place more professors? That ignores the fact that most people don't want to be professors. Should we do take-home pay? How uncivilized. It does however, have the advantage of being a realistic assessment of your value to society.

Once you eliminate ways to compare programs, the relative value of programs is dependent entirely upon reputation. For instance, we have a reputation as a "Top 10 medical school," when, in fact, we're not. Not even close. But the strength of the Dupont brand is such that we seem that way. Or something. The whole 'not top 10' is based on US News's rankings ( which, in the absence of better data, will be the way med schools are ranked (which should be incentive for developing alternate rankings). Let's look at the rankings and methodologies ( Reputation. Reputation. (This counts for 40% of the score, btw). NIH grants total, and per researcher. How this affects the quality of my MD-only colleagues education, I couldn't say. Note that the total is more heavily weighted than the per-researcher, thus encouraging schools to add mediocre scientists.

The next part is hillarious. Acceptance rate - what this has to do with quality, again, is unclear. Plus it encourages schools to drum up applications. Also, is this based on primary applications, or secondaries? A primary application costs $30 and all you have to do is check another box on the common app. To do a secondary, you actually want to go to the school. MCAT - yes, let's replace using board scores for a test that wonders whether you remember your cyclohexane chair conformations ( from OChem. Undergraduate GPA - . Enourages schools to accept people that avoided PChem and/or classes that they thought would prove difficult - these are precisely the sort you want for your physician, no?

Faculty/student ratio is interesting. Note that's faculty members per student. We're not in undergrad anymore, dorothy. And while I would appreciate getting picked apart by 9.5 professors if I went to Harvard, I'm not sure I would notice if it was only the 4.5 that would be after me at Hopkins. Again, this encourages schools to hire more crappier professors, or relabel reserach assistants and other non-helpful people as 'teaching faculty.' Next to these metrics, board scores and %1st pick for residency seem downright brillant.

The third criterion rejected by Poobah is student satisfaction. I've heard the argument before: I have no basis for comparison. I don't know whether my level of knowledge is actually good or competitive, only how it measures in the eyes of the very people I'm rating. Just because I had a good time in class doesn't mean I got anything out of it. But, as Poobah says, we're good students. We went to top schools. We take out knowledge and try to think about problems. We have a basis for comparison - it's called undergraduate. I've been taught physiology before, and I know when they're doing a bad job. We're here to learn, and we can tell the difference between when the professor is imparting useful information, imparting details about their research, and goofing off, and we rate them appropriately.

Saturday, October 22, 2005

Circular Reform I

Obviously, Dupont needs to change the way it educates its students. I'm not talking about obvious, low risk, and brilliant moves, like rehiring Dr. X. That's far too petty. Rather, DuPont needs to completely rejigger its curriculum, and in doing so leapfrog ahead of other medical schools and have:


We got a speech on this matter from one of the GRAND POOBAHs of the medical establishment.^1 It occured at noon, after a morning's worth of classes. Lunch, paradoxically, was not served. One of the constants of medical school is that when they want you to do something, there's free food. Nonetheless, the entire 250-seat auditorium was filled, with numerous upperclassmen sitting on the stairs. First, the dean got up and introduced the poobah. They went through this guy's whole pedigree (Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard)^2 Note that he's ~60 years old. Is that philosophy conversation he had with Chas during the Eisenhower administration really this important? Fortunately, they also went over all the crap he's done since then.

About midway through the resume, I was struck by a thought, "How cool is it that we live in the age of empiricism, where all the resume in the world does no good if the data is against you?" And I resolved that I wouldn't believe a thing unless I got the data. I have a grad class where people will refuse to give any credence to a paper because there's a shadow in one of the gels. Should we require the same standard before we muck up a generation of Dupont grads?

1 Saying who would be too much, but this was one of the top 20 people in medical education. Think deans of medical education, AAMC apparatchiks, medical education 'experts,' psychology types etc.
2 That's preschool, grade school, high school, undergraduate, post-baccalaureate research, MD, PhD, residency, fellowship, professoriate, chairmanship, initiative directorship, and deanship. As I wasn't taking notes, my rendition may be slightly innnacurate.

Has it been this long

And nothing has really gone on? The honest answer is yes. I am of the opinion that in order to write, you must have something you want to say. This is part of the reason I got out of writing as a field - I don't think that my ideas, in and of themselves, are of much originality or value. In my case, I've got nothing to push against.

The pressure of summer is basically gone. I no longer study every night. If I did, I would be so far on top of everything it would be ridiculous.* I try to amuse myself with pathology conferences or radiology visits, but scheduling for them is inconvenient given the amount of class I have. It's becoming obvious that I can improve my day immesurably by simply skipping the first lecture of any given day.

Why is the pressure of summer basically gone? It's simple. Anatomy and histology are two large concept areas where I had no previous knowledge. Zero. We receieved bone sets our first day, and I couldn't identify squat. Histology didn't start out as pinkish bluish ovals, it started out as 'can't focus on the image 'cause I don't know how to use a microscope.' Contrast that with physiology. Our med physio class is 100 'hours,' long, whereas my junior level physiology was 75 'hours' (Or 90 or 105, depending on how you want to count the lab) and taught on the same, if not a higher technical basis. The prof at Norbert, for instance, did us the courtesy of assuming we understood metastable kinetic states, and how they related to sodium channel opening (in a purely qualitative way, but still informative). For grad courses, Cell Biology and Proteins (my biochem course) are concepts I've heard before, just slightly embelished. Cell Death can surprise, like when we learned about mitochondrial calcium absorption, but it's more of an integrative class that stitches together what we already know than one which introduces big volumes of new data.

One might wonder why Physio is such a waste of time. Is it the variety of incoming preparations? My physio experience is certainly not representative, so this may have something to do with it. Is it the professors insistence on not telling us things, even in outline, that other people will teach us, and recapitulating how patch-clamp works 50 times? I'll give an example: Two weeks ago, we were lectured on the various membrane proteins involved in Long-QT syndrome, and then tested on what they were. I surveyed about 10 people in my class, including a few MSTPs, and no-one knew what QT referred to, or why it would be bad for it to be long.** It takes me about 5 minutes to explain this in simple terms any beginning med student can understand. Why don't the profs do this? Finally, the first years have a lot of other stuff to do. Physio has a rep for being an easy class where you just study the old tests, which is basically true. Our anatomy-heavy curriculum doesn't give it sufficient time to elaborate to the point where it would be revolutionary for me.

I guess I do have some stuff to say, though admittedly it is just dumb griping. We did get a lecture from a medical bigshot on how to reform our curriculum, so that will be a lot of fun if I ever do write about it.

* Why would being on top of everything be ridiculous? First, it would make classtime a complete waste. Second, I need to recouperate and save my powder for when it really counts. Third, I'm a gist kind of learner, sloppy intellect with a long memory for concepts. Hard work would just clean up the details, which would ultimately blur anyway.

** QT refers to a measurement done on EKG. It works like this, on EKG, each heartbeat has 3 big waves. The P wave is the electrical signal from the atria contracting and priming the heart. The QRS complex is 3 waves clustered together that represent the ventricles squeezing blood out into circulation. The T wave represents the ventricles relaxing. The QT interval is the amount of time (x-axis) between the beginning of the QRS complex and the end of the T wave, that is, how long the heart is contracted for. If this is too long, it means that the heart will still be contracting after all the blood has been squeezed out. It would be far more efficient to relax and let in the next round of blood. Failure to do so means that less blood gets pumped. This is 'bad.'

Saturday, October 01, 2005

Powerful Medicines I

At the White Coat Ceremony the Gold Foundation for Humanism in Medicine gave us two books. One of them is On Doctoring, a collection of stories, poems, and essays about medicine. It's unobjectionable. The other is Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs. 70% of primary care medical visits result in a prescription, and thus it's important that we get it right.^1 The conceit that this book is essential or useful needs to be examined more thoroughly.

This is going to be a fairly lazy book report. The first thing I'm going to do is take a poke at the author. Actually, the only thing I have on him is that he's been at Harvard since 1969 (p 231), and he's still only an associate professor. This is probably because he's too busy running the Pharmacoblahblahblah divisions at The Brig so it probably doesn't signify.^2

I would, however, like to take aim at Bernard Lown, M.D., winner of the Nobel Peace Prize and possibly one of the biggest malpracticers in medical history. A bit of background: Your heart has a normal rhythmic beat. In some people, a heart attack or other some such causes the heart to become very a-rhythmic. These people are at high risk of keeling over with no warning, a phenomenon known as "Sudden Cardiac Death." As it turns out, if you study most people, we have a few arrhythmic beats per day. Lown (and many others) figured that if a lot of arrhythmic beats are bad, a few are still a problem. Lown proposed that treating mild arrhythmia would prevent Sudden Cardiac Deaths. With no evidence other than Lown's say-so, thousands of physicians began prescribing the treatment for mild arrhythmias. When a clinical trial was finally conducted, they found out that the treatment caused sudden cardiac deaths, rather than preventing them.^3,4 The whole story appears in Deadly Medicine: Why Tens of Thousands of Heart Patients Died in America's Worst Drug Disaster. Deadly Medicine calculates that around 50,000 excess deaths occurred because of Lown's conjecture. However, a 1997 paper argues that no extra deaths appear in the epidemiology as a result of doctors trying to suppress mild arrhythmias.^5 Regardless, Lown hectoring about the need for evidence-based medicine is pretty rich.^6 It's also interesting to note that Lown is a (the?) senior physician at The Brig, and thus in some way Avorn's boss.

Next post: The problems with the content (as opposed to the dust jacket).

1a. What this means: You have a problem that you decide needs medical attention. You visit your family doctor, pediatrician, internist, woman doctor. There is a 70% chance that this individual will prescribe you something. This doesn't include getting referred to the dermatologist and the derm. giving you something.

b. Factoid from Clinical Skills - 75% of diagnosis are made on the basis of history alone, and 90% are made from a combination of history and physical exam. History is everything the patient says. Physical exam is where you take weight, height, blood pressure, get your knee tapped etc. etc. This seems to imply that most prescriptions are given on the basis of minimal information. You may argue that for someone with high-blood pressure, not many tests are necessary besides taking their blood pressure during the physical exam. I would counter that a lot of people are getting prescriptions for antibiotics without getting a culture taken to see if they actually have a bacterial infection. Over-prescription of antibiotics leads to antibiotic resistance, so this is not an academic problem.

2. The Brig (and indeed any of the Harvard Hospitals) is considered one of the most desireable places to go for residency.

3. Everyone was so convinced that arrhythmia suppression worked that they wouldn't enroll their patients in a trial and risk them getting a placebo. At a conference where the primary investigator was describing the results, one of the attendees stood up and said, "You are immoral!" (this is from Deadly Medicine).

4. Pratt CM, Moye LA. The Cardiac Arrhythmia Suppression Trial: background, interim results and implications. Am J Cardiol. 1990 Jan 16;65(4):20B-29B. PubMed

5. Anderson JL, Pratt CM, Waldo AL, Karagounis LA. Impact of the Food and Drug Administration approval of flecainide and encainide on coronary artery disease mortality: putting "Deadly Medicine" to the test. Am J Cardiol. 1997 Jan 1;79(1):43-7. PubMed

I know nothing of epidemiology, but their method seems rather unsophisticated, especially given what Avorn says about epidemiological research.

6. Lown's quote is actually about "the corrosive effects of commerical influence... Thus, to poke fun at him for this, I have to go into how his arrhythmia suppression hypothesis required the development of new, more easily tolerated, drugs to give to patients that didn't feel ill. It was because of this theoretical market that the drug companies chose to develop the new drugs. Lown's hypothesis provided the rationale under which they were able to sell their drugs to more patients, including those outside the category for which the drugs were initially improved. Thus, Lown arguing about the need for evidence-based medicine is rich, as is Lown arguing about the corrosive effects of commercial influence.


We had a professionalism day. This is the day where they tell us that professionalism is difficult to define, invite us to dialogue about professionalism, lecture us for five hours about professionalism, then tell us that we're ready to be professionals.

Anyway, Dean Hillary* is asking us about the merits provided by professionalism. Then she asks, "These merits may bring on a tragic flaw... does anyone have any idea what that is?"

Hubris. It's always hubris. Life as a Greek tragedy. I raise my hand.

*Not their real name.

Clinical Skills: The science of communication

This class, the whole "you're a doctor now" class is pretty boring. Our first lecture was on how important communication is. Then we had a lecture on how to talk to people, "Ask open ended questions... Give non-verbal reinforcement (mmm-hmmm, head nodding etc.)... Summarize what your patient says." This is mostly good for a few bad jokes.

I: This summarizing thing is so stupid. Won't people just get annoyed?
C: So what you're saying is that summarizing is annoying.

S: So how old are you?
I: I'm 25
S: How long has this been going on for?
I: Couple months.

I: Why did you come in today?
S: My knee hurts.
I: No. NO NO NO NO NO! You're getting it all wrong. It's supposed to be your knee.

Anyway, research indicates that first year medical students take a better history than upperclassmen, who take a better history than residents, and so on up the medical ladder. The solution ot improving patient-doctor communication? ABOLISH MEDICAL SCHOOL.

The whole communciation thing is unsurprising to me because even in normal conversation I try to do the same things, have ever since I un-gave-up on the non-supernerds. I've been accused of trying to make stilted and controlled something that should come naturally. On the other hand, it's transformed a lot of anemic conversations, so I'm willing to work with the science of communication. In principle.

An excess of normality

Something strange happened this week - it was dull. Dupont over the summer was like nothing I've done previously. Conversely, this week has felt like part of another year at Norbert. Lots of sitting in lecture and paper reading. I even had to write a critique adjudicating between two different viewpoints of a single phenomenon which were articulated in readings - just like an English class. The material was also much more comforting. I have much more experience with ion channels and lipid bilayers than I do with cranial nerves and brachial plexi. There two exceptions thus far - autopsy conference and clinical skills, which I'll post on... maybe.