Kelley M. Skeff, M.D., Ph.D., warned his audience in The Anlyan Center auditorium not to nod off as the lights dimmed over his PowerPoint. “I’m very good at picking up cervical dislocation,” he joked, referring to the possibility of nodding heads. On the screen was a triangle with three points: physicians, patients, and disease, and bidirectional arrows connected each point to the others and to the surrounding environment. The arrows highlighted the relationships among physicians, patients, disease, and the wider environment. “Which of the arrows in this diagram do you think Yale University focuses on the most?” asked Skeff, before prompting audience members to discuss the question with their neighbors. At once, the crowded auditorium erupted in conversation.
It was clear that Skeff had hit on a topic of great interest in his keynote address—“The Evolution of Medical Education”—at the School of Medicine’s second annual Medical Education Day. Skeff is the George DeForest Barnett Professor of Medicine at Stanford University and co-director of the Stanford Faculty Development Program. His work on clinical teaching methods and his faculty development program have shaped medical education all over the world. But his address at Medical Education Day was less a talk about effective teaching and more of an example of it.
“Where would you say the greatest problem lies in the delivery of health care?” Skeff asked the crowd. The response was no less enthusiastic than the previous question. Even with his microphone, Skeff had trouble making himself heard over the conversations that still filled the auditorium when the three minutes of discussion time had passed. He acknowledged major issues facing health care and medical education today, including patient-physician communication and patient access to care, but Skeff focused specifically on the physician’s relationship to the health care environment. “Many believe that the system of care is demanding of physicians, and they have no influence over it at all,” he said. However, physicians have not only the ability, but the responsibility, to propose changes in health care if they see the potential for improvement, according to Skeff. In closing, he challenged the group: Where can you personally have an effect on patient care?
“Today we come together as a community of educators, teachers, and students to learn from each other and think together about medical education,” said Richard Belitsky, M.D., HS ’82, FW ’83, deputy dean for education and Harold W. Jockers Associate Professor of Medical Education, in his opening remarks at the June 3 event. Medical Education Day is sponsored by the Teaching and Learning Center, whose mission is to inspire and support excellence in teaching at the School of Medicine—a key element of the school’s strategic plan for medical education that is in the process of implementation. “We set out as one of our important goals to elevate the status of teaching and to make more public and visible the work of medical education here at the medical school,” said Belitsky. “We wanted to find more and better ways to support the innovative and creative work that you do to improve medical education here.” Since its opening in 2012, the center has become an academic home for educators at the School of Medicine.
Following the keynote address, attendees chose among 10 workshops facilitated by Yale faculty. One workshop, facilitated by France Galerneau, M.D., associate professor of obstetrics, gynecology, and reproductive sciences, and Geoffrey Connors, M.D., assistant professor of medicine in the section of Pulmonary, Critical Care, and Sleep Medicine, and the associate program director of the Internal Medicine Traditional Residency Program, focused on developing clinical reasoning skills using a modified Bayesian method.
Clinical reasoning—the mechanism by which clinicians gather and process information to generate a diagnosis and a plan of management—becomes automatic for seasoned clinicians, so much so that they often become unaware of the steps involved. “The further along you get in your career, the harder this actually gets to teach,” said Connors. “We need to find a way to open our brain up to the student.” That’s exactly what the method provides—a step-by-step breakdown of what many clinicians are already doing on the wards, slowed down so that medical students can learn about the process.
The workshop participants worked through the steps with a case—a 64-year-old man with shortness of breath. The four-step process included gathering data to fill in the patient’s medical and social history, using that information to create the differential diagnosis, assigning a probability that a given diagnosis is correct to the five most likely diagnoses, then reassessing those probabilities after carrying out a physical exam and ordering relevant tests. A critical feature of the method is giving the students a framework for a disease—teaching them how to organize and categorize the information from the fact-gathering steps. “That’s often one of the more valuable things they take away—‘how do I organize these thoughts?’” Connors said.
“I think this field is really blossoming right now,” said Galerneau. “There’s a lot of literature and interest in critical thinking and clinical reasoning.”
Another workshop provided participants with the opportunity to discuss how David A. Ross, Ph.D. ’04, M.D. ’05, assistant professor of psychiatry, and Dana W. Dunne, M.D., associate professor of medicine, have designed and implemented resident-as-teacher programs. Residents across clinical departments play an integral role in the education of medical students, but few receive formal training in teaching. According to Dunne, prospective medical students are noticing. “When you have an articulated [resident-as-teacher] program, it’s almost like a recruiting tool,” she said.
The workshop addressed both the aims and barriers to a successful program and focused on the principles that went in to the development of the resident-as-teacher initiatives in both the medicine and psychiatry residency programs. Though the needs and obstacles of such programs vary by department, participants used those models to design a plan for creating a similar program in their own departments. According to Ross, any department looking to create a similar program can turn to those in the Yale community who have already developed resident as teacher programs. “There’s no need to reinvent the wheel,” said Ross.
At the end of the day, Awards for Excellence in Medical Education Research were given to psychiatry resident Tobias Wasser, M.D., for research in keeping residents safe, and to medical students Rebecca Liu and Serene I. Chen, and Pinar Oray–Schrom, M.D., director of the Wednesday Evening Clinic, for their research on the importance of a longitudinal primary care experience for medical students.
Awards for Excellence in Educational Innovation were given to William Zucconi, D.O., assistant professor of diagnostic radiology, for his studies of teaching radiology trainees, and to Susan Forster, M.D., chief of ophthalmology at University Health Services, and Janet Hafler, Ed.D., associate dean for educational scholarship, for ideas to improve the teaching of critical thinking in the ophthalmology module.
For more information on the Teaching and Learning Center, visit http://tlc.yale.edu.