Monday, September 17, 2012

Thoughts on QR codes at Medical Conferences

I am just back from Med 2.0. It was a great conference that did so many things right. One of the things that was right, was that every talk, every poster, every rapid fire session has its own web page. Here is what the top of those pages look like:

The square in the upper right, if you'r are not familiar, is a QR-code. All posters are supposed to use this label and all presentations are supposed to display this graphic on the title slide. When you scan the code with a smart phone (you can find an excellent free, QR-scanner for the iPhone here, life hacker endorsement of said scanner here), the smart phone will open up the web page for the talk or poster. Cool idea. Unfortunately, it was poorly executed by most presenters. Here is a typical title slide:

Using my iPhone from my seat in the middle of the auditorium, I had no chance of getting an accurate scan. Since I am one of those annoying conference participants who photographs every slide, I have found myself scanning my MacBook screen to get the links. Absurd, and really no easier than using the conference website to search for the presentation page. The right way to do it is the way John Ainsworth did it in his presentation on using Drupal to create a low tech, no software, SMS-notification system across 11 countries, 6 languages and 3 time zones:

Sunday, September 16, 2012

Medicine 2.0: Conversations from the hallway

This week-end I am in Boston at the Medicine 2.0 Conference. It has been awesome. I am tweeting and bloggin about it at eAJKD (blog | Twitter)

At one of the sessions on medical education, I made a comment on Beaumont's mandatory medical student attendance. Afterwards, Brian Alper, the founder of DynaMed came up to me to talk. He started to tell me about Dynamed, I told him I was familiar. When I was working with the students on the Team Based Learning, a number of them told me how much they loved the product. They even told me that it was better than UpToDate, a statement that gave me chest pain.

I had to tell him about my terrible experience looking up Goodpasture's in Dynamed. He looked at me and said, "So, you're the one."

He was totally professional and pulled up the current version of the topic on his iPad. Wow! What a change. The topic looks completely rewritten and in a comprehensive style. It now has an author, a wide variety of treatment options including plasmapheresis and immunosuppressants. He told me that he would email me the topic. I plan on revising my review of DynaMed, but for now all I can say is that it looks a lot better.

Friday, September 14, 2012

Chicken Noodle Soup versus Normal Saline. Fight!

More than a few times this week, I have found myself prescribing Jewish Penicillin, chicken noodle soup. CNS is rich in sodium so it is just about the best way to prescribe volume repletion in the out-patent arena. So i was delighted to see one of the dietician students projects on display in the hospital:

1720 mg of sodium per can of Swanson 100% Natural Chicken Broth (two 240 mL servings per can). So how does that stack up against old faithful, normal saline?

Normal saline has 154 mmol of sodium per liter or 3,542 mg of sodium per liter (154 mEq x 23 mg per mmol, the molecular weight of sodium), so a can of chicken soup is equivalent to about half a bag of normal saline.

Update: I don't get many good comments on Blogger but I got this pitch perfect comment on Twitter:

Tuesday, September 4, 2012

Team based learning, reason for optimism about medical education

In general, as I have progressed through my education, I have felt that the quality of education has been on a downward vector.
  • I believe that duty hour work restrictions have diminished continuity of care and reduced the drive for residents to read and learn about their patients, because the patients feel less like "their patients."
  • I think the emphasis on fraud prevention that has meant that attendings need to see and be present for all of the meaningful aspects of patient encounters has diminished fellow autonomy and delayed the maturation process that senior residents and fellows undergo.
  • I think the addition of alternative medicine curriculum to medical schools is an inexcusable retreat from the goal of medical scientists.
But I have recently experienced a vision for the future of medical education at Oakland University William Beaumont Medical school and I am blown away. Don't worry future doctors are going to be just fine.

OUWB is one of the newest medical schools in the country and has it's first two classes of medical students enrolled, classes of 2015 and 2016. The second years are finishing up the renal section. It is an integrated unit including histology, pathology, physiology and pathophysiology. I was privileged to have an integral role in developing the curriculum. One of the parts that I spent hours on was developing Team Based Learning modules (TBL).

Typical MD Lab from Scott Hall
Team based learning is OUWB's version of the small group learning sessions that have always been a part of the first two years of medical school. During my years at Wayne State they were called MD Labs. The sessions were sprinkled through out the curricula. I went to a few and they were of widely variable quality. I didn't go to many, because they didn't count toward your grade. That told me that The Dean didn't think they were important enough to count so I took the hint spent my limited hours cranking on stuff that counted.

The TBL is a reinterpretation of those small group sessions that I see as wildly successful. The success is not by accident and comes from the novel structure of the sessions. A TBL is made up of preparation and three segments:


The preparatory reading is a chapter, or article or handout that covers all of the main ideas of the session. For proteinuria and glomerular disease the students were assigned a chapter in Harrison's. For CKD and AKI the students were given review articles in BMJ (Hilton R. 2006) and NEJM (Abboud, Henrich 2010). For Sodium and Water, I wrote a 41 page chapter on the subject. Be warned I have been told that it has a lot of typos.

Individual Readiness Assessment Test (iRAT)

As soon as the session starts the students have a multiple choice test of 10 questions. All of the answers should be found in the assigned reading. The test score is part of the students grade in the section. This means that all of the students need to do the prep work and all of the students need to show up for the session. Two huge improvements to the Wayne State MD labs.

Gunning for grades on the iRAT

    Team Readiness Assessment Test (tRAT)

    After completing the fill-in-the-bubble iRAT, the students then work in 5 person teams on the exact same questions they just answered. The teams have scratch off pads that work like instant lottery tickets with the correct answers. When the team answers a question they get instant feedback if they were right or wrong. This is closed book but the students all work together. After the all of the teams complete their tRAT there is a brief discussion of any questions that were troubling. The proctors walk around the room during the exercise and listen to the team discussions to they get a sense of what questions are difficult/poorly written.
    If you scratch off three horse shoes you win $60.
    Look at her notes. Every tricky nephrology
    question starts with "let's draw a nephron."

    Application Exercise

    Application questions are complex questions that supposed to integrate physiology and clinical medicine in to a complex multiple choice question. The questions are all open book, and in this age of WiFi, laptops and the WWW, we should really rename open book as open Google. The teams get 15-20 minutes per question and then simultaneously display their answer. Then the proctors lead a discussion on the reasoning behind the answers and different strategies the teams used to get to the answer.

    The things I love about the TBL

    • It is part of the grade. Curriculum directors need to understand that the medical school curriculum has more information than is possible to learn and students are rational actors. They will sacrifice important but uncounted learning opportunities in order to prepare for counted exams. There is no way to make something meaningful without making it part of the grade.
    • The iRAT happens right when the students walk in to the room. I love how this makes it clear that the students are being graded on preparation. The important thing is getting the students to learn the material before the session starts. This paragraph from Regis School of pharmacy states it perfectly:
    "To promote active and collaborative learning, students are sometimes asked to work in groups in class or on projects outside of class. While group work does benefit student learning, unfortunately it is often plagued by “social loafers”, or students who do not pull their weight in terms of helping the group. As a result, many students learn to dislike group work and may seek to avoid it. TBL is different. TBL ensures that each member of the team is held accountable for their own learning outside of class. Students who do not prepare adequately before class will perform poorly on the iRAT and will not be able to contribute in a meaningful manner to the tRAT and application exercises. As a result, most students who would normally remain “social loafers” in a group learning project are instead quickly motivated to do the assigned work out of class in order to perform well on the iRAT. In addition, as teams work together and compete with other teams in the class, loyalty to the team develops among each member. This further motivates the “social loafers” to prepare outside of class so that they can contribute and help the team succeed."
    In the cut throat world of medical school any system that allowed a "social loafer" to benefit from the group while contributing nothing would be a recipe for a short lived project. The iRAT gives a clear message: come to class prepared, or you will suffer.

    • The application exercises are open google. To me, this was the most interesting part of TBL. Clinical medicine is, of course, open book. Everyday I am consulting Dr. Google, Epocrates and UpToDate. My information gathering strategies were developed on the fly in my clinical practice. No one taught me these types of skills and no where in medical school were there any opportunities to practice hone them. The students of OUWB are working together, comparing notes, seeing which resources work best. I heard students explain the virtues of DynaMed (a POS in my opinion). I spoke with students who distanced themselves from Wikipedia until I told them I was a fan and had no reservations about using the crowd sourced encyclopedia. After hearing me extol its virtues they quickly changed their tune and agreed that it was easy to filter good from bad wiki pages (referenced, with mainstream journals, avoid political topics) and that the good ones never steered them wrong.

    People used, Google, Wikipedia, UpToDate and a strange
    resource called a "book


    The portable computer revolution of iPads and smart phones allows us to bring the library to the bedside, it is time for medical schools to appreciate and embrace this pivot in the history if medicine. TBLs are the best example I have seen of of this.

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