Niches, Itches, and Medical Education

Stop for a moment and define the word, ‘niche’.

[ pause… ]

Do you have a niche? How did your niche become your niche? Was it always part of your DNA? Did a mentor inspire your niche? And why does it matter if you have a niche at all?

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The Oxford Learners’ Dictionary defines ‘niche’ as, “a comfortable or suitable role, job, [or] way of life”. I favor this definition of niche because of the inclusion of the word, ‘comfortable’. One might be well-suited or well-trained to perform a specific job, but that doesn’t necessarily mean they enjoy their work or are comfortable in their role. Comfort implies happiness, authenticity, and -- potentially -- joy.

Medical educators encourage trainees and junior faculty members to identify professional niches that they can develop over time. The argument is simple: working in domains related to your clinical role adds variety to your day-to-day schedule. Variety is the spice of life, and in medicine, a variety of tasks may reduce professional burnout. 

Expertise in domains such as patient safety, research, administration, medical education, and quality improvement are all examples of professional niches that physicians pursue within medicine. Medical schools deliberately design longitudinal curricula that provide students with experiences in such domains. Both Stanford School of Medicine and Northwestern Feinberg School of Medicine offer ‘concentrations’ aimed at niche development.

Residency programs offer similar longitudinal curricula, however the outcomes of these programs take many years to study. Northwestern Emergency Medicine launched ‘The Academic Colleges’ program in 2006, with a focus on just three career paths: Research, Administration, and Education. Program evaluation of their Education College occurred after 10 years of ‘graduates’, through interviews with program alumni, faculty members, and current residents. Expertise in four areas of medical education were identified as key outcomes of the program: educator skills and learning theory, education research methodology, educational program administrative, and collaboration. Read more about this program evaluation published in AEM Education & Training in 2017.

If you are an educator who directs a similar ‘scholarly tracks’ program, consider how you might conduct an evaluation of your curriculum and identify meaningful, longitudinal, learning outcomes. Here are some program evaluation resources from BMJ 2003 and Medical Teacher 2012 (AMEE Guide No. 67) to get you started.

As for itches… Merriam Webster describes the relatively recent trend from NICH to NEESH. I’m sticking with niches and itches -- seems classic.

August 11, 2019

Co-Authors of Original Article: Benjamin Schnapp, MD, MEd – University of Wisconsin and Abra Fant, MD, MS - Northwestern University.

Let's Go Back to the Bedside

There is clinical teaching… and then there’s bedside teaching. Some of our very best clinical teachers rarely go to the bedside with their learners, a trend that has worsened over the past two decades. Why? And how do we get our clinical teams back to the bedside?

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Image from upsplash.com

Sir William Osler said it best, ‘‘Take [the student] from the lecture room, take him [her] from the amphitheater. Put him [her] in the outpatient department, put him [her] in the wards. No teaching without a patient for a text, and the best is that taught by the patient himself [herself].” 

Osler’s call was to bring students from the classroom or the laboratory to the bedside -- to perfect their physical examination skills, to observe the professional behaviors of their mentors, and to be observed performing patient care by their preceptors. Today, the challenge isn’t to get students out of the classroom, but rather away from the electronic medical record. Our learners are charting, billing, and physician-order-entering all day long… often on workstations on wheels, in hospital hallways, just yards away from their patients. 

These same patients desperately want time with their physicians. And they trust us less and less, as a profession, because they don’t see us hard at work taking care of them — in the hallway.

What changed?

The answer is likely multifactorial, with some obvious causes. Our hospitals are overcrowded. Clinical performance metrics push us to work faster, with a paradox of less time spent in direct patient care. Documentation is a time-intensive and complex task, a response to litigation risks and billing rules. Supervising physicians are pulled in many directions, but rarely in the direction of the bedside. 

And what’s worse? Trainees who are taught in hallways teach in hallways. Our profession is forgetting the bedside teaching skills that Osler so passionately endorsed.

There are expert medical educators among us who are trying to retrain faculty members to teach at the bedside. Two Stanford courses are noteworthy for those interested in becoming better bedside teachers: Stanford25 Skills Symposium: Promoting the Culture of Bedside Medicine and the Stanford Faculty Development Center Clinical Teaching Program. Similar training (or, retraining) courses are popping up around the country, should you be unable to make your way to Palo Alto to participate in one of these fantastic programs. I also refer you to the Society for Bedside Medicine if you want to learn more about this topic and opportunities for skill development.

In 2006, Amer Aldeen and I published Bedside Teaching in Emergency Medicine in Academic Emergency Medicine. This article reviews the critical importance of bedside teaching to medical education, the historical decline of this professional skill, and strategies to overcome the above listed challenges.

Check out the Stanford bedside teaching courses, the Society for Bedside Medicine, our article in AEM… and let’s go back to the bedside with our trainees.

July 26, 2019

Co-Author of original article: Amer Aldeen, MD – US Acute Care Solutions.

Where Did All the LPs Go?

Physicians must be competent to perform the skills of their respective specialties before completing residency training. Educators struggle to understand just how many procedures are required of a trainee to become competent. Is there a minimum number? Does it differ by procedure for each trainee? How many is ‘enough’? And what should educators do if there are too few procedures to go around???

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Our accreditation systems are designed to ensure patient safety, as a societal responsibility. Residency program directors attest to their trainees’ competence before graduation — as a safeguard. I was a program director and I lost sleep worrying about this expectation of my role. Were my residents ready? What if my mistakes assessing them led to their mistakes with vulnerable patients?

The worry – how many procedures is enough? – was a tough one for me. Every trainee is different and they each require a unique set of training experiences to become competent. The BIG however: there are a limited number of cases for trainees to learn from in teaching hospitals.

There, I said it. There are only so many chest tubes, crics, and LPs to go around.

As medicine advances, there is a slow decrease in the number of necessary bedside and surgical procedures required to diagnosis and treat a variety of acute illnesses.

Thanks vaccines and CTAs, but where did all the LPs go?

The math is as follows: if X is the number of procedures required to train a class of residents per year, and Y is the total number of procedures available, your program is fine if Y > X.

But if X > Y… you need to think outside the box.

Medical education has fundamentally changed in the last several decades. There are more trainees. There *may* be more patients. And there are certainly more training programs and teaching hospitals, sponsored by health systems that were previously and decidedly non-teaching. This represents both a challenge and an opportunity for educators who need to be creative in their search for ‘enough’ procedures for their trainees.

My research collaborators and I have some potential solutions for teaching hospitals and program directors to consider, in our article, “More Learners, Finite Resources, and the Changing Landscape of Procedural Training at the Bedside” in Academic Medicine.

May 26, 2019

Co-Authors of original article: Linda Regan, MD – Johns Hopkins University, Jeremy Branzetti, MD – New York University, Laura Hopson, MD – University of Michigan