What should medical schools be replacing lecture with?

[DoctorG2020]

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My school still gives in-person lectures with a few online modules throughout that are not mandatory. All lectures are recorded and available for student use. However, less than 10 students are actually regularly attending any of these sessions. My school has tried to implement question and answer sessions as well (seemingly transitioning into a "flipped classroom"), but students still don't attend these sessions.

Second-year students are focussed on mastering UFAP on their own. Is having any lecture or flipped classroom irrelevant? If these aren't being utilized by students, faculty seem to be wasting their time. I almost feel embarrassed for the lecturers who are speaking to an empty hall. Any opinions on what schools should look like moving forward? Should we basically be paying schools to administer us exams every so often to test our learning and be available for questions via email?

 

[Gorne]

Gone are the days of the traditional lecture. Watching a lecture at your own pace in the comfort of your own home is far more efficient than wasting the minutes/gas getting to campus sitting and waiting for the professor, etc. Mandatory group sessions should still occur in my opinion, to discuss cases, anatomy lab, learning how to gram stain/KOH prep, but they should be placed throughout the year strategically.

Second year is also not all about mastering UFAP. You'll find that the students who study out of UFAP the entire year are usually the ones who don't do as well on Step 1. There is a deeper knowledge gained from in depth lectures that is still required to be a doctor and to do well on exams that require critical thinking and a more than superficial knowledge of the science behind medicine.

 

[NotYou20]

Nothing really. Just get out of the way. Lectures by clinicians are generally helpful, but my school already has a lot of these second year so I wouldn't add any.

 

[operaman]

Very good question. I don't think anyone has THE answer as yet, but many schools are actively searching for it. The answers will largely hinge upon institutional resources and willingness to adopt a newer and better system while also finding ways to tangibly measure its success.

I wonder - what sort of curriculum would I want if I (gasp) had to do it over again?

I'd want to start with an anatomy and basic science boot camp for a few weeks. I'd want all lectures recorded and refined by trained pedagogues who understand how to teach well. In-person anatomy lectures would be replaced by faculty-led prosections in the anatomy lab demonstrating our dissection for that section, followed by protected student dissection time. I think I'd like a short boot-camp anatomy course at the outset perhaps more focused on bigger picture structures and relationships, followed by more detailed dissections and reviews scattered throughout the first two years that dovetail with other curriculum elements. The other basic sciences could be crammed into this beginning time as well, with recorded lectures and all those group lab activities that typically accompany these. Faculty and students would have collaborated on high quality anki-like cards for this material and students would use this both for studying and to maintain longer term retention of what is basically rote memorization material. Some of this material (the important stuff) would be incorporated into all preclinical tests to ensure that students were keeping up with their reviews.

After boot camp, I'd want the entire class split into smaller groups and each placed on its own unique track through the material. Each track would rotate through different outpatient clinics, inpatient services, and procedural areas that dovetailed with the current topic. There would be pre-recorded lectures covering the material and planned clinician-led chalk talks teasing out the more clinically relevant points. A block on endocrine physiology would have students working in endo clinics and specialty diabetes clinics every morning with relevant physical diagnosis sessions in the afternoons as well as protected study time. Cardiac physio would have students spending time in cards clinic as well as reading echos. There would be some additional anatomy lab tab with recorded lectures and faculty-led prosections highlighting more detailed anatomy that wasn't covered in the initial unit.

I could see a way to do all the normal antomy/physio/biochem during MS1 integrated with primarily outpatient clinic and procedural time. There would also be a focus to ensure adequate exposure to all relevant subspecialty fields.

MS2 would have a similar multi-track approach but also incorporate all the typical MS3 clerkships as well as abnormal path/phys typically taught in MS2. Here again you'd have relevant rotations tied to each subunit, such as renal path spending time on nephrology servies, dialysis units, reading renal biopsies with path, and seeing/doing renal ultrasounds. There would again be a few hours of faculty-led anatomy focusing on the system and more detailed anatomy, perhaps even working to correlate clinically useful imaging findings with the 3-dimensional anatomy you find in the cadaver.

There would be a generous step 1 study period followed by a third year with a little more flexibility depending on student interests. Maybe you could even have individual tracks set up for people depending on desired specialty if they already have one, as well as more general setups for those still exploring.

While I know many schools are doing early clinical exposure, nobody (to my knowledge) is truly integrating that exposure on a day-to-day level with their curriculum at large. Clinic availability would require you split the class into smaller groups, hence the idea of "tracks" that would let everyone rotate at different times and obviously exams would be staggered as well.

I like this approach because it's something I'd find interesting and tolerable even now.

 

[Grainagainst]

While I know many schools are doing early clinical exposure, nobody (to my knowledge) is truly integrating that exposure on a day-to-day level with their curriculum at large. Clinic availability would require you split the class into smaller groups, hence the idea of "tracks" that would let everyone rotate at different times and obviously exams would be staggered as well.

Dartmouth is kind of doing this - for the majority of M1 our "early clinical exposure" was working with standardized patients in the hospital sim lab. When we were learning cardio physiology the patients had chest pain; when we did respiratory they had asthma, etc. This means all students get basically the same patient interviewing experience, patients with problems we are in the process of learning about, and feedback from facilitators who don't have to worry about actually treating the patient so can devote all their time to critiquing your performance. We get released out into the real world towards the end of M1.

There are definitely pros and cons to this, but I really liked it.

 

[operaman]

Dartmouth is kind of doing this - for the majority of M1 our "early clinical exposure" was working with standardized patients in the hospital sim lab. When we were learning cardio physiology the patients had chest pain; when we did respiratory they had asthma, etc. This means all students get basically the same patient interviewing experience, patients with problems we are in the process of learning about, and feedback from facilitators who don't have to worry about actually treating the patient so can devote all their time to critiquing your performance. We get released out into the real world towards the end of M1.

There are definitely pros and cons to this, but I really liked it.

Yeah I think that's fairly standard at most schools - was at mine too. The difference with my proposal would be the every day clinical time that's tailored to your basic science material. Implementation would be a huge undertaking and would probably take a good school a number of years just to plan out much less implement, so hopefully there would be people much smarter than I am teasing out the details.

It wouldn't even be that hard to come up with meaningful tasks for students that reinforce underlying concepts. If you're studying cardio and essential hypertension, have the students in a HTN clinic doing a relevant ROS checklist with the patient that the attending could then review and sign and even use for billing (yes this is totally legal, we have patients doing this themselves already). There would be recorded lectures detailing the underlying physiology and pathology of these effects, and required quizzes that must be passed prior to doing each clinic to ensure people were staying caught up. With the new billing rules going into effect, you could even have students using checklists to perform and document basic HPIs and exams for these chronic complaints, thus easing the documentation burden on the supervising attendings while simultaneously forcing the students to learn what a good focused HPI looks like.

The pedagogical work is enormous and would require fitting each element of the curriculum with a relevant clinical experience and application and figuring out a track system that would allow each student meaningful well-timed exposure to each element. It would take time for faculty to record their lectures and have other faculty review and help refine them so they are concise and meaningful. Half of why students do UFAP is that Dr. Sattar is a much better teacher than most! If students had similar quality teaching for their school courses, I think you'd see them using them. Developing this would take time and faculty would need to be compensated appropriately, though I have to think they'd rather record lectures and use any freed up time in the following years to do something more meaningful. Perhaps you could have them leading short small-group meetings - debriefs after relevant clinical time to ensure people were making the right connections to their basic science material.

 

[Goro]

My school still gives in-person lectures with a few online modules throughout that are not mandatory. All lectures are recorded and available for student use. However, less than 10 students are actually regularly attending any of these sessions. My school has tried to implement question and answer sessions as well (seemingly transitioning into a "flipped classroom"), but students still don't attend these sessions.

Second-year students are focussed on mastering UFAP on their own. Is having any lecture or flipped classroom irrelevant? If these aren't being utilized by students, faculty seem to be wasting their time. I almost feel embarrassed for the lecturers who are speaking to an empty hall. Any opinions on what schools should look like moving forward? Should we basically be paying schools to administer us exams every so often to test our learning and be available for questions via email?

Anything that involves active learning.

Keep in mind that some people LIKE lectures, although these are probably a pool of students nearing extinction.

Distance learning isn't going to help you learn as a team,

What's UFAP?

 

[ortnakas]

Count me in the group of people who hates Death by Powerpoint. I did the PBL curriculum and while I hated self-guided anatomy, I loved it for the rest of pre-clinicals and thought it was really solid board prep, in retrospect, even if it didn't feel like it at the time. Having said that, the majority of learning in my program came from readings we assigned, not from the cases themselves, so it might be a little different than the supplemental PBL I hear a lot of complaining about.

I do find it funny that some of the best online resources are, if you think about them, pretty much just lectures (Pathoma is Sattar lecturing pathology plus awful yet perfect drawings, Sketchy is awesome drawings disguising a micro/path lecture, DIT and B&B are pretty much lectures, clinical years OnlineMedEd is Dustyn giving lectures that are clutch for Step 2 and shelves). Maybe we don't collectively dislike lecture.... just bad ones.

Anything that involves active learning.

Keep in mind that some people LIKE lectures, although these are probably a pool of students nearing extinction.

Distance learning isn't going to help you learn as a team,

What's UFAP?

UFAP = UWorld, First Aid, Pathoma (sometimes UFAPS = UFAP + Sketchy)

 

[zero0]

Just forget traditional lectures. UFAP all the way, with honorable mentions to sketchy and Costanzo.

2nd year students only care about boards.

No one remembers all the low-yield minutiae we vomit onto our tests 2 weeks after the fact anyway.

 

[NotYou20]

Count me in the group of people who hates Death by Powerpoint. I did the PBL curriculum and while I hated self-guided anatomy, I loved it for the rest of pre-clinicals and thought it was really solid board prep, in retrospect, even if it didn't feel like it at the time. Having said that, the majority of learning in my program came from readings we assigned, not from the cases themselves, so it might be a little different than the supplemental PBL I hear a lot of complaining about.

I do find it funny that some of the best online resources are, if you think about them, pretty much just lectures (Pathoma is Sattar lecturing pathology plus awful yet perfect drawings, Sketchy is awesome drawings disguising a micro/path lecture, DIT and B&B are pretty much lectures, clinical years OnlineMedEd is Dustyn giving lectures that are clutch for Step 2 and shelves). Maybe we don't collectively dislike lecture.... just bad ones.


UFAP = UWorld, First Aid, Pathoma (sometimes UFAPS = UFAP + Sketchy)

Yeah the real change in the last 5 years is that everyone has access to excellent lecturers. Most of my profs aren't really bad...they're just not good. They don't add anything online resources don't, and they frequently miss important concepts/teaching points. They serve no purpose for students that aren't struggling.

 

[mistafab]

The thing is - the lecturers are speaking to an empty hall, but the vid is watched by 100+ students. The ego of the lecturer isn’t stroked, but the actual learning that occurs due to their work is probably increased due to recorded lectures.

The best thing a school could do is still have normal lectures and just show each teacher how many plays their lecture had. That would boost the ego.

Active learning sessions or not my favorite. Why? My classmates are stupid. The teacher will ask 10 questions and waste 20 minutes because no one wants to participate or just give the darn response. The lecture is much more useful than the active learning. A full 50 minutes of novel ideas presented with explanations by experienced faculty is absolute GOLD.

 

[xClashx]

Online Med Ed (once he finishes the material for first 2 years) + Uworld + Standardized patients + Some group cases for discussion.

 

[DoctorG2020]

The consensus here seems to be that more clinical practice would be beneficial, but I'm not sure that students would really be receptive to that. At least for second year students, I think that they would still be motivated to study for Step 1 only (i.e. dedicate all of their time to UFAPs) and feel that they were wasting their time. I know it may not be what some people want to hear, but most students around this time are motivated by a number/score and forget about the end goal. It would reduce student satisfaction and increase anxiety.

I just feel that the few things a student may learn in a 4 hour clinical experience may be beneficial down the road, but they would likely gain more studying board review material during that time to achieve their short-term goals.

The thing is - the lecturers are speaking to an empty hall, but the vid is watched by 100+ students. The ego of the lecturer isn’t stroked, but the actual learning that occurs due to their work is probably increased due to recorded lectures.

The best thing a school could do is still have normal lectures and just show each teacher how many plays their lecture had. That would boost the ego.

Active learning sessions or not my favorite. Why? My classmates are stupid. The teacher will ask 10 questions and waste 20 minutes because no one wants to participate or just give the darn response. The lecture is much more useful than the active learning. A full 50 minutes of novel ideas presented with explanations by experienced faculty is absolute GOLD.

I agree with your point about active learning sessions. As far as watching the videos back (at least at my school), there is no way that 100+ students watch them. I would say that of the second year students, maybe 10 max would watch the videos back. It seems like a waste.

 

[operaman]

The consensus here seems to be that more clinical practice would be beneficial, but I'm not sure that students would really be receptive to that. At least for second year students, I think that they would still be motivated to study for Step 1 only (i.e. dedicate all of their time to UFAPs) and feel that they were wasting their time. I know it may not be what some people want to hear, but most students around this time are motivated by a number/score and forget about the end goal. It would reduce student satisfaction and increase anxiety.

I just feel that the few things a student may learn in a 4 hour clinical experience may be beneficial down the road, but they would likely gain more studying board review material during that time to achieve their short-term goals.



I agree with your point about active learning sessions. As far as watching the videos back (at least at my school), there is no way that 100+ students watch them. I would say that of the second year students, maybe 10 max would watch the videos back. It seems like a waste.

Maybe this is a bigger picture issue than curriculum redesign, but with the current USMLE system I think there will inevitably be tensions between what students want and see as their most important short term goal, and what schools and faculty know they need to learn to become good physicians. All of us who have taken Step 1 (and 2 and 3 even) know how relatively meaningless this material is for clinical practice, but we also acknowledge its paramount importance for securing a residency position and advancing ones chosen career.

I think the easiest way for schools to address this is to allot a generous dedicated study period, maybe 2-3 months rather than the traditional 4-6 weeks. This would give students more than enough time to binge UFAP plus whatever other resources are in vogue at the time while allowing them to focus more on their immediate coursework.

The more difficult approach would be to train faculty in writing NBME style questions and design all class exams and quizzes to utilize boards-equivalent questions. There would have to be a faculty consensus to minimize testing minutiae and focus instead on testing true integration and understanding. This would free students from the grind of memorizing meaningless details to crank out those last few "AOA points" on exams and let them focus instead on the critically important material. It would also help train them to answer multi-level boards style question which is a skill that takes time to develop.

The pie-in-the-sky but arguably best solution would be to make Step 1 a pass/fail test entirely with scaled scores released only in aggregate to schools for monitoring their own teaching and detailed breakdowns only to students who fail the exam so they can better prepare for a retake. Step 1 was designed from the beginning to be a test of minimum competency rather than a screening test used to select residency candidates (compared to the MCAT which was actually designed to assess readiness and aptitude for medical school). I have to think a number of faculty would rally behind such a change because this singular focus on test prep is an oft-lamented fact of life in medical schools and probably does detract from important learning. I'm sure students would appreciate a pass/fail test as well! Functionally it's scored much that way already with scores needing to be 16 points apart to be considered significantly different and outside the range of random scaling variation! Considering how it's used to stratify candidates often on a +/- 10 pt basis, it's well past time for some rethinking.

 

[shortcoatdream15]

Khan Academy tbh