The future of health education | Martin Pusic | TEDxLangleyED



so I'm a pediatric emergency doctor I sit in an emergency department and treat kids and that's what I've done for a lot of years and in fact worked at the BC Children's for for a while but nowadays then why you what I do is four days a week I teach and so they die so I like many of you I'm a teacher and have to worry about the issues and many of the issues that have been raised today I go from talk to talk to talk and think of yeah that impacts medical students and that and and you know answer each of these things seems to have relevance well so what I'd like to do though is to show you some of the differences in medical education I'll talk about in general terms in terms of what at what we do but then show you one example one task that we train people at and try and show you the complexity of what we're trying to do and maybe you can maybe it'll resonate with you in terms of what you're trying to do with there with kids so medicine is changing and so that I saw in Canada in the United States wherever you are we go from you know so we used to be focused on the Marcus Welby doctor individual patient and that was completely the the center of the thing that's still very very very important but now we think more broadly in terms of systems in terms of population-based care we used to we used to think just in terms of the one time you showed up in my office you were my problem but now we think more broadly about sort of when you should be in the office how often you should come back and so that and how to interact in a continuous fashion we used to be individuals the solo practice now we now we're much more team-based and and I could regale you with the with the size of our teams and the complexity of them the young and it used to be the locus of control was mine I was the doctor I knew what you needed and I would prescribe exactly what she needed well now the patients come in with this stack this big of Internet printouts with ideas on what they need and and so that I am real is sort of it now I'm off to the side and I'm the coach and well yeah that one's right but do you mister maybe did you think about these ones and so used to be anecdotal used to be that you wanted your doctor to be gray hair and so that so that your doctor had collected a thousand stories that were like yours and then we'll choose amongst those stories and get down to where where you were at now it's all evidence-based its research what does the latest study research shows that sort of thing you want that Daniel pink here's a study that exactly applies to your situation and then it used to be that the majority of care was in inpatient in hospitals that's all moved out and only the sickest of the sick or in the hospitals now and all sorts of things happen in the ambulatory care settings we're trying to cope with this through technology and so I won't go through each of these but but that the top left there is an electronic patient record the middle thing is is a sensor that you can buy for thirty five dollars on Amazon to tell you how badly your smoking is affecting your oxygenation Google glass is maybe relevant to what we can do this um there where it says eighty I can clip on to my iPhone and stick on to my chest and get an immediate electrocardiogram that thing cost two hundred dollars and on the bottom right is the stethoscope replacement two handheld ultrasound so they don't have to listen to your heart anymore I see it medical education has to change because of all of these changes and so that um so there's a lot of things that we we have to think about that are different our learners are cadillac learners they come in and they have done a great job on their multiple choice tests however you know sort of a don't worry your doctor is our best multiple chest choice test taker ever is not something that you want to hear is it so we have to we have to can't our system and in fact there's an identity ship that happens halfway through Medical School where you go where you go from multiple-choice test taker to we want to change your identity you to clinician change your identity from you are a 97.8% I can't remember the exact number we're using but the to you matter as far as how your patient is doing we have to think of now about you know sort of used to be that I was rewarded for memorizing a lot of drug dosages and facts in the like and now they all sit on my on my smartphone and how am I gonna how am I going to get that to switch from sort of me memorizing things to you integrating the smartphone and that's an educational task and then how do i how do I retain the person the the emotion of medicine imagine saying your father has died and so how do you teach that and how do you guard the humanity of the whole thing in the middle of all of this technological change and then finally you know sort of week and we think about this radiating drop in the bucket where and I can affect you during medical school but I have to think about the chain from me teaching you and you treating them the patient and then the patient going on to going on to into the whole wild of how Wella of what can happen to a patient and so that these ripples on the pond we're trying to captivate it but he gets you know I don't really want to measure your multiple choice test score as to who you are I want to measure your patients compliance with their diabetes regimen and and and judge my education based on what's happening at the level of the patient and really what the health of the patient is so we've got tools and so that at NYU do we discarded our old microscopes that we use for a cetology in favor of a virtual microscope we've we've we've integrated a new you know so they went in and they digitized a human body and created a in essence a digital cadaver and so that is so this cadaver it's an app that you can download for ten dollars from from the iTunes Store and you can you can find every single muscle every single nerve every single eye every single artery every single vein and it's all named it's all labeled for you can rotate it you can do all of that kind of thing and we've and and sort of as part of this we've integrated these tools right into the cadaver labs we're trying to preserve the best of the traditional sorts of things and then merge in the technology so that you can write on the spot have the advantages of the virtual while you have the advantages of the of the real so here we've arrayed our hunkiest medical students to show you our 3d visualizations of this thing and so what happens is is that app gets projected onto a screen and they've done these special glasses so they can see it in 3d and so they can get a real sense of the three dimension at three dimensionality of anatomy and really refine their mental models and explore in a way that we never could before and then um and then the other technique that we brought in is simulation in that in networks and we're sort of learning from the airline industry and trying to recreate those scenarios that only happen every once in a while but when they do happen there it's extremely extremely important so the person who collapses and is about to die and you have four minutes to resuscitate them in this team-based sort of thing thirteen people descend on that person in order to try to save their lives and so those 13 people would be that are never the same 13 people and yet they have to come together which each having their own proper role in each being mission focus while the whole thing runs and so that we practice that over and over and over again mannequins that mannequin costs $100,000 and the reason that costs $100,000 is it allows us to recreate these situations in a way that's safe and and effective so I'd like to this is an audience participation part of this talk okay so I'm working in the BC children's and in comes a ten month old child with fever and has had a cough for three days so doing take the story and then the resident orders a chest x-ray and this is the chest x-ray you see what do you see the left lung doesn't look so good Hey okay good so so ten months old I'm working in the BC Children's it's flu season there's there's fever and cough everywhere they're hanging off off the rafters they're in the waiting room the waiting rooms three hours everybody's mad and you know sort of sort of coping sort of trying to trying to do my bit so we get this check this x-ray and so when I go to look at the x-ray and when the resident came back and said I think there's there's maybe a left-sided in a moment and so that if you if you look back in here it's sort of in behind the heart there's a pneumonia looks white and so that this white stuff you know sort of could be pneumonia and people would argue about whether or not this is a pneumonia here so that's and you don't want to hear this but it was sort of a eight out of ten radiologists would say that is a pneumonia two out of ten would say it isn't and you know sir there's a bit of variability to that but as as we heard from the front row look at this rib okay so this ribs horizontal this is the back of the rib this ribs horizontal this ribs horizontal on this side is horizontal horizontal horizontal these are all straight but this one's canted off at an angle right right in here so that's different so so so part of the task is is like go into it with this mindset this is pneumonia and when in fact it's it's a I have to pay attention to something that's complete that that I don't necessarily wouldn't focus on and with my mind's eye the problem for me is is that this is exactly where ribs fracture when you when you have child abuse and so there's somebody who gets shaken like this the rib fractures in exactly that spot and so that is a physician now I'm faced with a dilemma okay so that is so that as teachers you're mandated reporters of child abuse is so you recognize this this this dilemma but you know sort of it's really a fracture then you know sort of a sort of then I'm up in this quadrant I say there's a fracture there is a fracture and and we're good right so that I but um but if I say that's not a fracture and it is one I've missed child abuse or as if I say there's an old fracture that well if if that isn't a fracture and I said it was a fracture then I've created a situation and what I have in front of me is a lovely family so that I so it doesn't look like there would be any issues or anything along those lines okay so to rather just quickly tell you the story the person we ended up activating the whole machinery after a couple of days interviews in the whole bit it was all fine and so that everybody concluded that this was just the way this kid was built but you can see the complexities and you can see sort of sort of what the what the issues can be like and so on so what so what we've done in the meantime is we've sort of gone on I'd like to use that example to show you how how we train people in terms of deliberately practicing this skill of reading x-rays so that on so here's a here's a here's the thing that we've created in which it's one of those you make the call things and we're so we show you an ankle x-ray and then the person considers this ankle x-ray and then has to declare it either normal or abnormal sort of up here and we put these qualifiers on probably indefinitely and again you don't want to hear that the doctor says probably a fracture but um but but wait they do this and then they get immediate feedback okay you were right long did you put the yellow dot in where the fracture is or digit did you miss it so that I so it gives you feedback and and in bad educational theory manner when they get it wrong they get this big red X in this red and it says incorrect and so so that on so we get people to practice one case two case two hundred cases over and over again and we can generate for each person you know serve across the number of cases that they do a learning curve where there's this index of goodness that says you know sort of initially you're not all that great but gradually your learning curve comes up here and you get better and better it won't surprise you to see that there's a lot of even amongst our cadillac medical students a lot of variability and so that some of the people come into this pretty good and some come in not very good and but you know sir by and large the majority of them learn in this paradigm so when you average this all out you get a nice sort of a thirst and learning curve but if you put everybody's learning curve on here you can see that some people just don't have an aptitude for this where some people are outstanding and so what we've done ever accomplished is and say you know so we started off really really wide and we decreased the variance so that we clearly people are learning and we're doing our job of moving the whole average up but even there at the end after two hundred and thirty four of these repetitions there's still quite a bit of variability so what we're trying to do in medicine is accommodate this kind of variability and so that it's a acknowledge to the past even even the most standardized group of individuals will be variable and and to acknowledge the complexity of the context and and still move people through so that on so all of medicine is act on now on this competency movement this isn't new to a group of educators but we're trying to move away from knows those multiple-choice questions notice how it shows how and can actually do and then to use my learning curve example what we used to do was that these to people we would we would assign go out there and do a hundred and fifty of these ankle x-rays but after having finished 150 you can see we would graduate people with different competency levels and so there's so there's this tremendous effort right now across all medical schools in North America to get off of that this time base assignment ace type of thing and this tends to say to assign a competency level like me with a pointer so that so that you have to attain this competency level which we will have determined is the safe an appropriate competency level for our patients and in fact in determining these competency standards went by patients to sit on those competency committees and say yeah that's about right in terms of in terms of that kind of thing and so they did so here I've shown you I show you two people know so this is that one from before already not bad at is had probably had some radiology training before and now is sort of gotten better and better and better as they go along was this person haven't had very much radiology training at all and so rapidly sort of learns the easy stuff but then sort of clearly has to work at it and is dancing around this competency line what we're trying to do is show people these things so to the extent that we can give them a cockpit give them a whole sort of information dashboard about their learning so they can say yeah this is where I am right now and to model you have to do 200 more of these or whatever it is and you're really getting it so it's a single example uses his ankle radiographs there's a lot more to being a doctor than being a good ankle radio graphologist but you can see the idea you can see the you know sort of a metacognitive aspect of teaching people about learning so that they can so that they can sort of carry that to whatever aspect of being a doctor it is and so that on so the in using these new technologies we're trying to sort of take the this of these medical students and yet at the same time get them to be adaptive learners and so that so what I'd like to leave you with is this graph and so that this is from from greatness and rapist and again it's a learning curve but it's a learning curve cutter kind of Pro across the the whole the whole of the enterprise and start off at and obviously you don't know very much but you gradually move up to being competent and perhaps proficient but in sort of we used to you know when when people learn how to drive they become automatic and they don't learn anymore and they stay at this level forever what we want from our doctors or to get up here but to keep on going and so that if I can teach them during the time that they're becoming competent how to learn these are our hope is is that they'll carry that forward out into twenty thirty you know sort when when we no longer have them but at the same time that they can adapt and and get better and better and better so that does so that at age sixty four and a half just before they're going to retire it's not a hanging on by the by the edges of their fingernails in terms of confidence but instead they're getting they're going out in a blaze of glory in terms of getting better and better at this thing thank you very much

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