Saturday 29 October 2016

Beyond Pharmacare

It's more bubbling under the surface than being a headlining issue, but national Pharmacare is steadily becoming a major point of conversation within the medical community. Most countries with universal healthcare include some form of provision of pharmaceuticals, if not outright coverage - Canada is the notable exception. As such, Canada has now become a patchwork collection of private insurance, industry-provided samples or give-aways, public welfare programs, and out-of-pocket purchases in order to provide these drugs to patients. It's not a particularly efficient approach, with high costs for patient health, economic prosperity, or even balance sheets for government agencies.

What gets lost in the conversation is that when it comes to healthcare coverage in Canada, it's not just drugs that get the short end of the stick, it's most therapeutic interventions. Big, hospital-based treatments - surgeries, inpatient stays (including medication), dialysis, etc - are still covered, but non-pharmaceutical outpatient therapies rarely get adequate funding. The two that spring to mind most readily are physiotherapy (PT) and mental health therapies, notably Cognitive Behavioural Therapy (CBT). PT is a main component of treatment for most non-critical musculoskeletal injuries and in many cases, may be the only or main component to effective treatment. CBT is the first-line treatment for most cases of anxiety (which is exceedingly common) as well as a component in many other mental health treatment plans.

There are now some funded programs for both PT and CBT, but they naturally have long wait-lists. As a result, the rest falls on private insurance and out-of-pocket spending. The concern, as with medication, is cost. PT and CBT both involve having a qualified healthcare provider spend significant time with a patient. In-person contact is expensive and the public healthcare system is understandably hesitant to provide coverage, particularly if these treatments need to go on for some time.

In most cases though, neither PT nor CBT should go on for an extended period of time. PT and CBT have primary benefit when they teach patients exercises or skills to deal with their conditions. A single PT appointment may be enough in mild cases. CBT requires a few more, but a short course is often sufficient if the patient is compliant and motivated. There's always the possibility of therapy needing to go on longer than intended - but the same can be said of medication.

I'm very hopeful that Pharmacare becomes a reality - I've already seen far too many patients struggle with getting necessary or helpful medications. No doubt more fail to get important medications without their healthcare providers being aware, as research on compliance with medications in the setting of economic difficulties makes absolutely clear. Yet, as coverage for medications expands, I do worry about these outpatient-based, non-pharmaceutical therapies falling by the wayside, especially when these interventions are often more effective than pharmaceutical alternatives. Looking towards my future practice, I find myself taking a decidedly "drugs if necessary, not necessarily drugs" attitude. I want a public insurance system that supports such an attitude.

Tuesday 25 October 2016

Problem-Based Learning - A Follow-Up

I'm of the viewpoint that you shouldn't criticize the actions of others without having a reasonable alternative to offer. I'm not a fan of traditional lecture-based medical education, and just wrote a post against one of the more popular alternatives in Problem-Based Learning (PBL) curriculums, so I should probably provide some sort of third option.

Lectures, PBL, any other approach in education is simply a tool to transmit information. Like any tool, they can be used effectively or ineffectively. Hammers work great on nails, not so much on screws. Lectures are amazing at conveying large amounts of information quickly to large groups of people. However, unless an instructor is particularly capable, lectures are terrible for information retention. PBL is great for information retention, but terrible for information transmission. Used in conjunction, these approaches can maximize efficiency in education. Introductory information is conveyed via lectures in bulk, then emphasized and expanded upon with appropriate problems.

Many schools employ some version of this combined approach, but not necessarily in a well-constructed manner. Sometimes one technique is relied upon too heavily. Sometimes the timing or coordination is problematic, such as providing a PBL task before a lecture, or so far after it that retention from the lecture is minimal. Deliberately using both techniques together, as two parts of a whole, is preferable.

In reality though, the tools themselves are flexible and can be adapted to account for their weakness. Lectures can be interactive and entertaining, maximizing retention. PBL can provide concise supporting resources, or have knowledgeable instructors available to provide context and guidance. Yet achieving these adaptations is easier said than done. Strong lecturers are surprisingly rare. Having adequate numbers of instructors for PBL for an entire curriculum is expensive. As such, combinations of approaches may permit less-than-ideal versions of these tools to be sufficiently effective given basic resource constraints.

If I were designing an educational approach from scratch, my emphasis would be on the basic points of educational psychology that too often get neglected - scaffolding, context, and repetition. Clinical education is so effective because it naturally includes all these elements. Pre-clinical education is often so ineffective because it fails to incorporate them. Repetition in particular is sorely lacking.

My preferred structure for medical education would be based around repetition. If a piece of information isn't conveyed at least three times within the span of a month or so, to me, it's not even worth teaching, at least not at such an early stage as during pre-clerkship years. I would like to see another tool, one which has a good evidence base behind it, used more frequently - formative assessments. Formative assessments are wonderful because they eliminate the pressure for short-term learning seen in summative assessments, while providing an opportunity to identify gaps in knowledge.

So here's my ideal set-up: in the first week, lectures, small group discussions, or readings would be given on a set of associated information. This transmits the information. The second week, a formative assessment is given testing all the transmitted information. This assessment is taken up with students to identify class-wide and personal gaps in knowledge. The third week, an applied, context-heavy session is held. This could be PBL, Team-Based Learning, physical skills instruction, anatomy lab, or really anything that requires some application of the knowledge outside a classroom setting. Ideally, this would adapted to the weak points in class' knowledge based on the formative assessment. Four-to-six weeks later, a summative assessment is given to test the students' knowledge, forming the basis of the students' marks. Even though this is a graded test, the results of the test should be given to the students to identify any remaining deficiencies in knowledge. Evaluations are necessary, but they're also one of the best ways to learn, and I've never understood why schools place such a high priority on keeping test answers secret. Yes, I know they want to keep future classes from just studying the questions on the test, but it's a poor excuse. Either schools are failing to ask a wide enough variety of questions on their tests (question bank is to small for the amount of material provided or they're recycling a limited number of idiosyncratic questions), or all the pertinent information is in those questions they're asking and in that case, who cares how students learn that information - that means they're getting all the necessary data!

The main weakness to my approach is that it's a bit more time-intensive for each fact that gets presented. You can't give nearly the same number of lectures if you're losing a day or two each week to formative assessments or application tasks like PBL. I strongly believe this to be a worthwhile trade-off. While less information is provided to students, more should be retained. More importantly, what information is retained should be more consistent student-to-student. Consistency matters when setting expectations for subsequent steps, such as in clerkship. I found it baffling that I could know nothing about a part medicine that I learned about in pre-clerkship and no one cared - what was the point of those first two years if I could start right back at the beginning without consequence? What I did remember of course came in handy, but what I retained from pre-clerkship and what my colleagues retained from pre-clerkship was at times shockingly different. Clinical instructors have to set the bar very low when there's such variability in learner knowledge.

I'm starting to ramble, so I'll try to wrap this up. In medicine, clinical education will always be the most critical aspect. I've argued before that we should substantially reduce pre-clerkship education, or even scrap it entirely. However, realizing that clinical educational opportunities are limited and that having some base knowledge before seeing patients helps protect both students and patients, I doubt we'll ever eliminate pre-clerkship education. So, if it must exist, I think it could use a revamp, to become more efficient, more effective, and for its results to be more consistent. It doesn't take more money, or more time, or fancy educational innovations. It just requires some variety in instruction techniques and a focus on applying the basics of educational theory thoroughly.

Saturday 22 October 2016

Problem-Based Learning

One of the new trends in medical education, particularly in the US, is Problem-Based Learning or PBL. PBL posits that letting students explore topics openly, with goals and guidance rather than tasks and obligations, will lead to greater investment in learning by students, as well as overall better retention of knowledge. Extending on this idea, PBL often involves students working in teams - Team-Based Learning or TBL - to allow students to share knowledge more freely and to work collaboratively towards a solution.

In theory, PBL addresses a lot of the objections I have to the current "standard" approach in medical education, particularly in pre-clerkship. I find the lecture-heavy, test-based format I went through to be rather inefficient and puts students in a fine position to burn out or put in a token effort. Yet, I'm very skeptical of PBL, particularly TBL, in the way many schools seem to want to use it.

Central to my concerns with PBL is that to solve a problem, you first need the tools and knowledge to do so. Giving students the freedom to choose an approach, or putting them in groups to work together, does little to overcome any gaps in necessary knowledge students inevitably have when training to become a physician. PBL proponents will argue that having students explore to find that background knowledge helps retention - and undoubtedly it does - but it's also very inefficient unless students know exactly where to look for that information. For example, it's very important for students to know the first-line treatment for simple UTIs. It's basic knowledge anyone who's finished clerkship should be able to pass along. Yet, if you were to search for that information, you'll quickly get about a half-dozen different answers, all of which are partially correct, but picking out the standard conventional answer is impossible without being given some actual instruction by a knowledgeable person. A naive learner simply won't have the context necessary to discriminate between imprecise recommendations available. The freedom to explore an answer - or the benefit of collective thought - simply doesn't contribute in the way guided instruction would.

Once all the necessary background information has been learned or provided, PBL works great at putting it all together. Moreover, putting all that knowledge together can help with retention of those facts. TBL can further enhance this by letting students fill in each others gaps in knowledge, since no student gets everything right 100% of the time - even the best students forget something.

Unfortunately, the goal of pre-clerkship is largely to give students that background information. Putting it together is left for clerkship, which essentially functions like a natural form of PBL. Clerkship has the additional advantage of authenticity, an often-overlooked trait when trying to motivate students to work. For all its promise of enhanced student engagement, PBL suffers from much the same drawback as traditional instruction - goals are set by the program, not by the student. PBL becomes just a different hurdle to jump over to move onto the next step. The motivation to do well remains extrinsic, even as engagement increases. In clerkship, the presence of an actual patient to empathize with - and the fear of disappointing preceptors invested in their patients well-being - provides some intrinsic motivation.

PBL and TBL can have an important role in education, particularly medical education, but their use needs to be tailored to their strengths. These techniques should be used to solidify knowledge already learned, not to teach new information. Most importantly - and proponents of PBL are quick to advocate this - instructors should be readily available to provide context and direction, as both PBL and TBL can quickly become troublesome if students' thoughts veer away from the correct path. As much as possible, PBL should be used where students already have motivation to learn, should be evaluated in a formative manner, and ideally the topic should involve some choice from students. PBL is a great tool, but it's not a panacea - it should be used where it's appropriate, and discarded where not. My experiences with PBL and TBL thus far have made me worried that educators might not understand where these tools are best employed.

Tuesday 18 October 2016

Familiar Faces

Unlike most elective students, I'm doing a good number of my electives at my home school.

Part of this was by design - as a student applying primarily to Family Medicine, I don't need to do nearly as many electives in one field, so I've got some extra elective time to spend on learning opportunities, on rotations I haven't experienced yet first-hand. Those can be done anywhere, so might as well do them in a familiar setting where I don't have to pay for travel or accommodations. Plus, I can spend more time with my partner and dog at home!

Part of this was definitely not by design - I had some electives at other schools fall through last-minute after months of waiting. Just a reminder that despite the new electives portal in Canada that is supposed make electives more accessible and to eliminate the need for elective-hoarding, there's still a major incentive to gather up as many electives as possible, dropping any excess ones as you go.

One unexpected advantage of this arrangement, however, is getting to see some patients I saw previously on my third year rotations. Seeing a familiar name, or stumbling across a prior dictation with your own name on it is pretty exciting! (Side note - dictation services do a pretty good job. Recently read a note I dictating very early in clerkship and superficially, it looks amazing! When I actually read the content, it's fairly disorganized and rambling. It does its job, but I feel I can do so much better at this stage and it only looks half-decent because the dictating service my hospital uses made it look that good).

This is not necessarily a common experience in medical school. We get shifted from service to service regularly enough that any continuity within these services is pretty short-term. Seeing a patient after 2 months isn't quite the same as checking in on them over a year later, but this longitudinal care is a core part of being a physician. Even as just a reminder of the growth we go through as medical students, I'm appreciating the experience. I know some schools, particularly satellite campuses, have been working with clerkship models that build these sorts of longitudinal experiences into their structure, and US schools having been piloting studies on longitudinal clerkship for years. From speaking to some people in longitudinal medical education programs, I've been given the sense that these set-ups are better in theory than in action, but there is some interesting research on the subject. Given my recent experiences, I would love to see effective longitudinal care fit more cleanly and reliably into undergraduate medical education.

Saturday 15 October 2016

Moving Up the Totem Pole

I'm now on my 4th elective, but it's my first one in a hospital setting after several rural or exclusively clinic-based electives. That means, in addition to triggering some lingering anxiety about hospital work, that I'm working with some 3rd year students. For the first time in my medical career, in a clinical setting, I'm not the low man on the totem pole.

As I'm a still a medical student, my role has not appreciably changed and the expectations have only increased marginally. However, it is a very different feeling, having that extra year of experience in medicine and, because I'm doing an elective at my home hospital, familiarity for the system I'm working in. It is a far less stressful set-up than 3rd year.

I'm also being given some authority and responsibility over my slightly-more-junior colleagues. I get a very small amount of control of the daily schedule as a result, which provides an amazing sense of liberty after a year of having zero control. I get to do a little bit of teaching, which I love - wherever my medical career takes me, I would like to be teaching for at least part of it.

Despite my supposed seniority, what has struck me is the capabilities of the 3rd year students I've worked with. Maybe I'm just meeting the best and brightest, maybe I didn't give myself enough credit back when I was a 3rd year, but they seem a lot more able than I felt back when I was in their position. In short, I'm impressed. I still have some information to pass along - I didn't get through that whole year without learning something - but it's not as wide of a gap as I thought it would be by this point!

Tuesday 11 October 2016

Bureaucracy

The fourth year of medicine is pretty good. You get a fair bit of choice over what you do and where. You get less call. There's no block exams and evaluations are considerably less stressful.

Where fourth year (and the process leading up to fourth year) is terrible is in its bureaucracy. Medicine, as a rule, is organizationally complex, which leads to a number of rather problematic inefficiencies. Today's fun bureaucratic hurdle is registering for the MCCQE Part 1. It's an important exam, without a doubt, the only standardized test we take in medical school. It's also part of our licencing.

As part of the registration process, the Medical Council of Canada (MCC) requires identification. Completely reasonable, this is a non-trivial test that is one of the few milestones we insist on to ensure potential physicians are sufficiently knowledgeable. Any cheating in the form of impersonation would be a serious concern. So, they have a fairly stringent requirement - a notarized copy of a current passport. It's a bit specific since not everyone has a passport, and many other valid forms of ID exist, so I wish they would be a bit more flexible in what documents that would take. However, in my case, I already had my passport notarized for CaRMS, so I can reuse it for the MCCQE Part 1.

But wait! Apparently a notarized copy of the document that gets me into other countries isn't good enough for the MCC on its own! They also insist on a separate, MCC-specific form, with two passport quality photos attached and to have that notarized as well. Why? No clue!

So, now I need to get more passport-quality photos, fill out this needless form, and get it notarized. My school is kind enough to have notaries available, but of course, they're only available during regular working hours in my school's city. Not terribly convenient for fourth year students on elective across the country who, even with the nicer fourth year schedules, are still never going to be available during regular office hours without taking time out of electives. I could have had this completed at the same point I had the passport notarized, but of course, had no idea this was a requirement and was never informed of the requirement by my school despite this happening every single year.

Sadly, situations like this occur frequently in medicine and cause numerous headaches for providers, patients, and families. This is just a taste, but it follows a familiar framework. We've got multiple organizations who are not co-ordinating well on a task that is a joint responsibility, with one organization putting up needless hurdles and the other failing to anticipate challenges in overcoming those hurdles. As a medical student with my future career on the line, it's extremely annoying. I can only imagine how patients feel facing similar circumstances with their health in the balance.

Saturday 8 October 2016

Bad Habits

Everyone has a few bad habits. These poor habits can be a significant drain on health and on quality of life. I think it's worth touching on one of mine as a follow-up to my previous post.

I get way too much screen time. I spend way too much time on my phone, computer, or watching TV. I'm on a primary care pediatrics rotation where I frequently talk about appropriate screen time for children (< 1 hr per day) and I can't help but feel like a huge hypocrite. The last time I got less than an hour of screen time in a day way probably back when I was a teenager and was camping out in the middle of a lake miles from any electronics.

Screens have become part of life for most people, so I'm hardly unique here, but my average day is probably about 75% screen time, if not more. It's a problem and one I'm definitely going to have trouble breaking. Realistically, I'm never going to be completely screen-free. I use screens for work, for school, for studying. It'd be impossible to function without screens in those situations.

However, there's a number of ways I can and should be cutting back on my screen time. First is with TV. I watch too much of it. I watch it reflexively. Don't even care if there's nothing on I want to watch, the TV is often there as background noise. We don't pay for cable either, so it's all Netflix or other streaming, not even something like the weather network or news.

Second is in keeping up with the world. The internet is great for getting news and discussing current topics, but it's also unbounded in these regards. There's always another viewpoint, another topic, another article that can be read. And I binge on this stuff. I don't think I'll ever stop this obsession with how the world works - it's part of why I went into medicine - but I would like to take some of these activities off-line. Once residency starts and I have actual money to spend, rather than a line of credit to increase, I'd like to start getting some print media sources. You know, actually pay for the information I get. If I can't break my information addiction, I can at least save myself some eyestrain while satisfying it.

Last and certainly not least - gaming. I like video games. And I have a history of video game compulsion if not outright addiction. I've probably spent about 10% of my total life - including time spent sleeping - playing one video game or another. My Steam collection has me at about 100 days of total playtime, which isn't too bad on its own, but neglects almost all of my major time-sinks. With certain games, I can waste an entire day without even realizing it. In the past, I've wasted far more than a day without realizing it. Sometimes days like this are benign or even helpful - a day off every once in a while is hardly a bad thing! But when it happens too often, happens when I really can't afford a day off, or happens without being planned, it just leads to more stress. Gaming is basically a hobby, and I need to be treating it like one, with regular, scheduled, and non-intrusive times set aside for it.

Getting more exercise and eating better were hard changes to make, but I think I've made a good start down that path. Cutting down on screen-time is going to be much, much more difficult.