February 26th, 2021

Toward a Pedagogical Shift

Sneha Shah, MD

Dr. Shah is a Chief Resident in Internal Medicine at the University of Colorado.

“If we teach today’s students as we taught yesterday’s, we rob them of tomorrow.”

— One summation of philosopher John Dewey 

The Why can’t I just Google it? Problem

Imagine seeing a patient with symptoms you suspect mighty be the result of a medication side effect. But you’ve forgotten the mechanism of action of this medication. You left your pocket pharmacology book at home, and the hospital library is 15 minutes away. There are no pharmacists on the wards for you to consult. I imagine there was a time when memorization in medicine was crucial. I am not saying it isn’t now, but I propose that it is less so. In less than 1 second, Google can tell me the mechanism of action of any medication. By conceding that the availability of lightning-fast information at our fingertips is an argument against memorization, are we doing a disservice to our learners?

Sherlock's mindPedagogical shift, proposal 1: Let’s teach our learners how and when to appropriately utilize modern, web-based tools. More importantly, let’s teach them why it is still important to engage in some memorization instead of always reverting to “Why can’t I just Google it?” If you’ve ever run a Code Blue, you know there are times when your memory must serve you under extreme pressure. I would like to see medical education emphasize the why instead of the what. Any modern learner can Google the what (i.e., what is the mechanism of action of labetalol?). So let’s set aside testing learners’ memories and instead re-allocate time to teach them why a master clinician chooses labetalol instead of another agent.

USMLE is already moving toward making Step 1 Pass/Fail; many medical schools are shifting to a longitudinal curriculum. As someone who has come from “bench to bedside” and now is arriving back at “the bench” for ongoing enhancement of my understanding of pathophysiology, I wish I would have been taught with the above lens.

The I don’t have time Problem

Residents of today have quite a bit asked of them! Pre-round efficiently, present that data flawlessly, tend to sick patients, admit new patients, run family meetings, discharge patients (ideally before 11AM), write your notes quickly but without copy forward so the attending can co-sign, and sign-out in a timely manner so you don’t break duty-hour restrictions. All this, along with the added pressure of attending educational conferences and reading about patients. It’s hard. I worry that the residents (and the perceived “cheap labor” they provide) have been misappropriated to doing more and more. Is there a way for residents to see a similar volume of patients but re-allocate their limited duty hours back to being learners?

medical residents looking at a monitor

Courtesy of CU IMRP

Pedagogical shift, proposal 2: Let’s challenge our learners to practice mental dexterity. With the ubiquity of workstations on wheels in many hospitals, is a model of “discovery rounds” better? Here, time typically spent pre-rounding can be spent at the bedside, reading about illnesses, and prepping the rest of the afternoon for success. This model may be more difficult for junior learners (medical students and interns), as it requires one to synthesize data quickly, assess the patient’s condition, and derive a plan. For senior residents, this may be the necessary way forward for critical clinical reasoning. This method might also help shift the traditional model of data transference (from the pre-rounder to the rest of the group) to one of dialogue.

The Stuck in a routine Problem

Everyone learns differently — some visually, some aurally, and some in a tactile manner. One of my favorite education philosophers is Paolo Freire. In his Pedagogy of the Oppressed, he writes, “education is suffering from narration sickness.” It is not by pretending we are empty vessels to be filled with medical knowledge that one becomes the type of provider they want to be; but rather by experiential learning through a growth mindset and empathetic dialogue will we become our best physician self. That’s a bunch of fancy words to say, as a chief, I notice a decline in enthusiasm toward attending educational opportunities and wonder why this is the case? What changes would the learners prefer?

Pedagogical shift, proposal 3: Let’s bring back the joy of teaching and learning. Celebrate being wrong in a safe space and use a dialogical and interactive model of teaching rather than narration. This has been a priority for me and my co-chiefs this year. We even created a “Stump the Chiefs” conference to get in the hot seat ourselves — which you can find on our YouTube channel. Why not try “reverse-pimping” while you’re on the wards? Here, the learners ask questions of the attending to determine how he or she catalogs a patient’s presentation and how a treatment plan is developed.  It is our duty to keep our learners engaged. It’s time to get creative, pique some curiosity, and make learning fun again!


Let us no longer rob our students of tomorrow.

 

NEJM Resident 360

6 Responses to “Toward a Pedagogical Shift”

  1. C Winter says:

    Curiosity is piqued not peaked but otherwise your suggestions are excellent!

    [NOTE from editor: Thank you. This error has been corrected.]

  2. Donald Steinmuller says:

    I agree. Closed book tests are not appropriate. All clinical teaching and activity as a MD provider should revolve around how to get the best information on the problem from resources like Uptodate and journal and/or internet search, asking opinions of peers and staff and then formulating the best and most appropriate plan with patient, recording plan in chart and communicate the plan to patient, co MD’s and other caregivers. Residents and fellows need to learn how to learn by doing these tasks supervised by attendings on rounds. All scut work, information gathering be done by non MD, non nurses, non therapists (use assistants, scribes. Or direct transfer from lab and medical equipment) and reviewed and supplemented by those directly interacting with patient and making decisions. Change is definitely needed. No wasted time. Spend the time with learning how to learn and patient and family interaction and formulating a best and Uptodate treatment plan.

  3. Nathan Wagstaff says:

    I don’t understand the difference between “discovery rounds” and “prerounds”. I read it 3 times, and they still sound the same to me. I am obviously missing something.

    • Sneha Shah, MD says:

      Hi Nathan,

      Thanks for asking for clarification. In many teaching hospitals (including all at which I’ve been a student or resident) have a system where here is how the morning typically goes:
      1. Team received signout from the overnight cross-covering team.
      2. Team starts to “pre-round.” Pre-rounding is an activity where student, interns, and senior residents will independently review patient records, write down pertinent information like vitals and labs, and jot down their plans for the day. Depending on how many patients one is carrying or how advanced they are in their career, they write a lot or a little. Pre-rounds also include, going to (in most cases RUSHING TO) see all of the patients. All of this is done without the attending.
      3. Then the official rounds start as the attending arrive. Some prefer table-rounds which are where the team including the attending sits down and discuss patients. Some prefer bedside rounds where the team goes to the patient rooms and discuss there. Both of these traditional models of rounds are where the students/interns present data they gathered during pre-rounding and present it to the attending.

      What I am proposing are “discovery-rounds.” Here, the learners would. not spend/waste time writing down vitals, labs, imaging results, and whatever else they spend time writing down during pre-rounds. Rather, the team would bring a computer to the patient’s room and present this data fresh to the team. The thought is then they can spend the traditional pre-rounding time actually talking to patients more, reading about diseases, or prepping notes.

      Hope that helps!

      • Mariana da Silva Jardim says:

        I just loved your ” discovery-rounds” idea. Optimizing our time so we can actually practice medicine by staying at the bed side taking care of our patients. This is what technology in Medicine should be about.

  4. Luiz A. M. Fonseca says:

    I was amazed that you have Paulo (this is the correct spelling, in Portuguese, Paolo is the Italian version of the same name) Freire’s pedagogy as one of your references. Here in Brazil we have the bad luck of currently having rulers who are trying to ban Freire from schools.
    I congratulate you for your choice.

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