Teaching Portfolio

Jeff Wiese, MD, FACP

Section 11: Teaching & Learning: Methods and Strategies

There are seven years of medical education from the college graduate to the practicing physician; my strategy has been to be a part of each of these seven years to ensure an incremental and successful development of the physicians I train.  

Year 1

My father’s strategy was to begin early; developing solid fundamentals before the complexities of the game made it impossible to return to fundamentals. I have adopted this strategy by beginning instruction in the first year of medical school. I have four goals to in my first year instruction:

1. Inspire professionalism as the fundamental goal of the physician.
2. Empower students with clinical reasoning as a method for discerning relevant clinical data.
3. Enable students to overcome the fear of touching a patient.
4. Provide students with a rational approach (Tier I/Tier II) to the physical examination.

This begins my departure from teacher to coach. The coach is responsible for not only enabling ability to perform, but also for anticipating the obstacles the player will encounter, and empowering him or her with the ability to overcome these obstacles when they arise. Unlike the vignette-based exams of the pre-clinical years, each patient on the clinical wards has infinity of data to provide. The most common pitfall in physician development is the student’s inability to discern between relevant and irrelevant data as it pertains to each patient’s presenting complaint. I anticipate this struggle, and I anticipate my students will be admonished by their attending physicians to,  “Obtain/present only the relevant data,” presupposing they will have a strategy for determining relevance. My goal in the first year is to instill in students the Bayesian theory of clinical reasoning such that they have a method for determining relevance in their clinical practice:

1. Use the characterization of the chief complaint to generate a differential diagnosis.
2. Use the differential diagnosis to determine relevant from irrelevant data.
3. Perform exam maneuvers and obtain tests that test the hypotheses contained in the differential diagnosis.

Albert Bandura noted that it is fear that prevents performance, and an expectation of fear makes the environment more daunting. As technology makes the physical exam more obsolete, I remain a proponent for the exam; not because I believe in the superiority of the physical exam over technology, but because I believe the physical exam brings the doctor closer to the patient. And the closer the doctor is to her patient, the greater the therapeutic result we can expect. I try not to over-teach the physical exam in the first year. My goal is to make students comfortable with touching a patient, absolving them of the fear that may someday keep them from examining their patient. I teach vital signs, and in concert with the Department of Physiology, the Tier I cardiac, pulmonary, abdominal, musculoskeletal, and neurologic examinations.

Perhaps a word about the Tier I and Tier II philosophy is in order. As a coach, I anticipate what the student will see when he enters the clinical wards. He will see residents and attending physicians performing partial examinations of their patients; and the content of these partial examinations will change from patient to patient. They will not tell the student why they perform some examination maneuvers on one patient, and different examination maneuvers on another patient. There is a reason for their variability, of course: their examination changes based upon their differential diagnosis, which of course changes from patient to patient. But this skill has become tacit to them, and they do not think to tell the student why they do what they do. The student will model their behavior concretely, mimicking exactly what they do. Without the rationale behind the action, however, the student will quickly become frustrated. To absolve the frustration, the student will abandon the physical examination, and the gap between this future physician and his patients will begin to widen. As time passes, the student (having not done the physical exam in some time) will become afraid of his inadequacy with the physical exam; this fear will prevent him from returning to the exam, and more importantly, to his patient’s bedside.

Anticipating this common occurrence, I developed the Tier I/Tier II philosophy to the exam. I teach students the Tier I exam: quick and easy screening maneuvers that should be done on every patient to detect common diseases unlikely to be obvious from the history. I also teach them the Tier II exam: maneuvers that should be done only to evaluate abnormalities detected on the Tier I exam, and to evaluate the diagnoses on their differential diagnosis. This approach enables them to discern why their physician role models do the exams that they do. Once students have made the connection between the differential diagnosis and the Tier II exam, they are better able to learn about constructing a differential diagnosis: they can glean the attending physician’s differential by watching his or her Tier II examination. The Tier I/Tier II layout is in the Red Diamond Syllabus (Section 8 Supplement).
In sum, my teaching in the first year is to establish the fundamentals of clinical medicine in order to empower the student to get the most from her second year of medical school training.

Year 2: Clinical Diagnosis and Biostatistics

I teach clinical diagnosis in the second year. The course used to be called Physical Diagnosis, but as the above commentary suggests, the goal of this course is much more than the physical examination.

The course begins with clinical reasoning. This is important in several respects. As their coach, I anticipate that students will struggle with two obstacles. First, their pre-clinical experience will have taught them to search for and recognize “buzz words.” A vignette on pneumonia, for example, must contain egophony to be a fair question, but the clinical reality is that many patients with pneumonia do not have egophony, and some patients with egophony do not have pneumonia. If this is not addressed and explained early in training, there is a risk that the student will experience frustration with the physical examination when they reach their clinical years. The sentiment might go something like this: “This exam thing is worthless! My patient has pneumonia, but the exam is normal. I’m throwing out the physical exam from now on.” It would be understandable to dispense with one physical examination maneuver; but the reality is that this sentiment prompts disposal of the entire examination. To counteract this, I teach students about tests in general: each test has a sensitivity and a specificity for each disease. The next step is in empowering students to understand how sensitivity and specificity translate into likelihood ratios, both positive LR’s (to make a disease more probable) and negative LR’s (to make a disease less probable). This is an important foundation; the remainder of the course describes physical examination maneuvers, with each maneuver’s positive and negative likelihood ratios, such that the student can not only learn how to do the maneuver, but also learn the confidence he can have in the maneuver if the result is positive or negative. The whole philosophy is captured in one of the courses four mottos (from Goethe): “Was mann weiss, mann sieht.” Translation, what you know (or what you look for), that is what you will find.

Of course the implicit lesson taught in this approach is that tests have meaning only in the context of the pre-test probability for a disease, and that tests (including exam maneuvers) have value only when examining a disease on their differential diagnosis. The clinical reasoning component of the course teaches students how to establish pre-test probabilities from their history and from the natural prevalence of disease. This is important, because in the midst of most physical examination courses, the patient’s history gets lost.  The Clinical Diagnosis course trains students to keep the patient’s history preeminent. With the history preeminent, the student physician must remain at the patient’s bedside, and this is the ultimate goal of this course: from the outset, create a system of thinking within the student that drives her to the patient’s bedside. The longer the clinician spends at the bedside, the more likely the patient will come up with the words to describe the disease; the more likely the disease will declare itself. And the word “clinician” is appropriate: from the French “clinique,” meaning “at the bedside.”

The final component of clinical reasoning is the testing and treatment thresholds. By a mathematical proof, you can prove that the decision to test for or treat a disease depends upon the risks/costs versus the expected benefits. If the probability of a disease is above this threshold it should be treated; if the probability is not above its threshold it should not be treated. The reason I devote so much time to this concept is to prevent a pitfall I anticipate the students will experiences in their clinical practice. The obstacle is the temptation to test for and/or treat all “scary” diseases. The erroneous clinical admonition they will receive is, “You have to obtain a spiral CT scan to exclude pulmonary embolism in all patients with dyspnea, because an embolism could kill the patient.” The error is that although a pulmonary embolism is potentially fatal, it does not necessarily make it probable. The argument is usually followed by some legal scare (“You’ll get sued if you don’t”), which is, as Peter Berger would put it “bad faith.” Bad faith is the abdication of reasoning and the abdication of responsibility for decisions because of a belief that there is not a choice. Hence, motto number two of the course: “All you have to do in life is die.” Once a student accepts this tenet, he is empowered with choice and thus responsibility: we choose to do things in life, including ordering tests for patients, if the expected benefits outweigh the expected costs. The benefit is that it puts the student physician in control of the test, not the tests in control of the physician, and this is the key to efficient resource utilization and preventing unnecessary testing that leads to subsequent unnecessary invasive procedures. As I coach the students, “No test is non-invasive; all tests are pre-invasive.”

The other implicit lesson is that students learn that clinical medicine is not about absolutes: to wait for 100% probability of a diagnosis (i.e., appendicitis) is to kill many patients who needed the therapy but did not receive it in time because the physician was waiting for 100% probability (i.e., The surgical tenet: 20% of all appendectomies should be normal appendices). Clinical medicine is a game of probabilities, and this is a lesson often missed by student physicians, since their pre-clinical vignette-based testing (by design) is quite the opposite; each test question has to have a 100% correct answer. Unless the student makes this paradigm switch from “100% certainty in diagnosis” to “sufficient probability to treat a diagnosis,” great frustration and inadequate care will result.

The long-term benefit of this coaching is not clinical; it is philosophical. The elimination of bad faith empowers students to take responsibility for their actions, both within and without medicine. This is central to preventing the learned self-helplessness that is used to rationalize unprofessional behavior. Once you accept choice, you accept responsibility. And unprofessional behavior has this at its core: it the abdication of choice, and thus the abdication of responsibility. Peppered throughout the course are lessons in professionalism, but I never admonish students that they have to do an action (i.e., respect a patient’s wishes), because the “have to” admonishment builds bad faith, and bad faith is the seed that leads to unprofessional behavior. Rather, I create the case for why respecting a patient’s wishes, for example, is the right thing to do because it leads to better clinical care, and because it is consistent with the good person within each student. Respecting a patient’s wishes is a choice, and we choose to do this because the benefits of the decision are great and right. Intermittently, I send students some of my writings and thoughts on the professionalism of medicine. A few of which are in Section 12.
 
The principle that guides my teaching of the physical examination is that the student should not memorize the association of physical findings with disease. To the contrary, the student should understand why the physical finding is associated with the disease. There are two reasons for this. First, memorized knowledge fades over time. Since my goal is Phase 4 Teaching (i.e., teaching for performance), it is silly to teach any knowledge or skill that will be lost in a year; the student will obviously not use a skill that has been lost. Second, the student that understands the pathophysiology that causes a physical finding understands the pathophysiology of the disease. Aside from bringing the physician back to the bedside, this may be the most compelling argument for teaching the physical exam. The better a student understands the pathophysiology of disease, the better he will be at treating that disease. And importantly, the better the student will be able to predict the consequences of his interventions. Case in point, if a student understands that a third heart sound (S3) is due to volume overload in the left atrium, he is more likely to understand that elimination of fluid from the body is the suggested therapy. There is no need to memorize that fact from a book.  

And this is important to clinical medicine. If our failure to find a computer that can practice medicine effectively (and it has been a failure) tells us anything, it tells us this: medicine is not a game of checkers where the player acts and then reacts to his opponent. It is a game of chess: the physician must make decisions not based upon the position of the pieces on the board at present, but rather based upon where he anticipates the pieces will be several moves into the game. Using the example above, the physician must recognize that diuresis is the therapy for a patient with fluid overload, but he must also anticipate that this will eventually result in less blood flow to the kidney, and thus worsening renal failure. Recognizing both, perhaps after-load reduction to allow the heart to mobilize more fluid, while simultaneously maintaining blood flow to the kidney, would have been a better initial plan.
Teaching the exam in the context of physiology enables the student to think like a chess player. When a student is empowered with understanding, instead of facts, he at least has a shot at deriving the right answer when the facts escape him. And since all facts are eventually lost from the memory if not repeatedly used (i.e., my Spanish-speaking skills I learned in high school), this preserves performance over time. It also enables the student to solve problems not previously encountered, which is very much a part of clinical medicine. Though not the goal of this course (clinical performance in third year and beyond is the goal) the dramatic elevation in shelf test scores, both for clinical diagnosis and pathology (see below) are surrogate evidence that this approach has been effective (Section 6).

The other departure Clinical Diagnosis has taken from a standard physical diagnosis course is to address the skills necessary for clinical performance on the wards. The course now has a “preparation for the wards” sub-course built in. The Green Emerald Syllabus summarizes these lessons (Section 8 Supplement). By lecture, students are taught how to use their clinical reasoning (vida supra) to construct their admission notes, progress notes, and oral case presentations. An active participation, seminar series of five, thirty-minute small groups allows fourth-year students (from the clinical coaching course; vida infra) to coach the second-year students in these skills. The small group structure, and the use of fourth-year students is important: this enables second-year students to ask the questions they need to ask, and it allows them to ask it of people they trust (i.e., those who have just gone through what they are about to go through).

The final component of my year two teaching is biostatistics. If there is a topic more prone to memorization, I don’t know of it. Instead of teaching formulas and complex statistical analysis, I elected to sacrifice the details and focus upon the statistical principles necessary for understanding the five major study types encountered in clinical medicine. The sacrifice of details permitted more time to discuss the principles underlying medical research. The goal is to empower students with the skills necessary to engage in practice-based learning early in their career, such that these skills might be fostered during their clinical years in preparation for a lifetime of learning. To this end, the three lectures are followed by five journal club sessions, in which the student’s performance is assessed (i.e., find the article using medline, evaluate the article using the Journal Club Kit) (Section 8 Supplement). The goal is to model the behavior the student should embrace during the remainder of her career. Students are evaluated by the quality of the portfolio their team constructs (Section 6 Supplement); the ancillary lesson is teamwork.

Year 3

My third-year teaching is an extension of the first two years. I routinely do three lectures per block for the Internal Medicine Clerkship. The first of which is advanced clinical reasoning that is purposely couched in the context of how to give an oral case presentation. The frustrating part of assessing clinical reasoning is that it is translucent. This makes it difficult for attending physicians and residents to assess a student’s clinical reasoning quality, and thus it is challenging to find the area for improvement. The spoken case presentation is the key to this challenge. If the SCP is constructed based upon the student’s clinical reasoning, the student’s clinical reasoning then becomes available to the attending physician to inspect and critique (See the American Journal of Medicine Article in Section 11). The added benefit is that it prevents the attending physician’s admonition, “Present only the relevant data,” which is a huge rhetorical error. This is a presumption of presupposed knowledge; that is, it presupposes that the student knew what was relevant and has elected to present irrelevant data. The problem is usually that the student has no definition of relevance. As discussed earlier in the narrative, the student by this point has hopefully (if I did my job) learned that relevance is based upon the differential diagnosis, which is the core of the clinical reasoning process. The goals of this lecture are three-fold: 1. To improve communication skills and thereby increase efficiency on the clinical wards (thereby, increasing teaching time on attending rounds), 2. To make the student’s clinical reasoning available for critique and improvement, and 3. To create a feed-forward cycle, where clinical reasoning improves the oral case presentation, and each successful oral case presentation further strengthens a student’s familiarity with the clinical reasoning process.

The other two lectures: The Ten Most Important Equations in Medicine, and ICU Medicine (in addition to other ad hoc lectures when a faculty member cancels) are standard knowledge-based lectures. I have to admit that these are probably the lectures I love the most, largely because I just love teaching and talking about clinical medicine. But then again, the principles espoused above apply here as well. The lectures are always physiology-based, with the goal being that while the student may enter the lecture feeling daunted by the topic, he will leave with a greater understanding of a topic that is now far less daunting. The goal is not to introduce new knowledge (textbooks are more effective than didactics for this goal), but rather to introduce new ways of thinking about the clinical topics, such that the knowledge seems to compress into a manageable, bite-size portion. Things really should be as simple as possible (so Occam, Einstein, and Osler would say), and my goal is to impart a method of thinking that provides understanding, and enables future problem-solving for clinical tasks not yet encountered.

Speaking of methods, you’ll note in the appendix box a copy of the Tulane Intern’s Manual. This is given to the students to provide one of Osler’s two central components to clinical excellence: methods and thoroughness. I authored this book in an effort to reduce the incidence of blind memorization and algorithmic thinking (the death of free thought) on the wards. It seems right to begin an emphasis on methodical problem solving, which is quite different from following algorithms, in the third year. I made it an intern manual such that the residents and interns would be the early adopters, and therefore the disciples of the principle of method-based care as they teach the medical students. The manual is designed to be, as Malcom Gladwell put it, “sticky.” It’s full of non-medical features (pager numbers, hospital phone numbers, restaurant guides, social calendars, etc) that keep it in the hands of the residents, interns, and now students. The results of this book have taught me a valuable lesson about Phase IV coaching: If you really want to affect clinical performance, you have to come up with methods that maintain the intended clinical performance even when you are not present. Eventually every student of mine will leave me; I can’t always be there to ensure they are performing the way I want them to perform. This book is my voice when I am not there; it has established a residency-consciousness of the importance of methods, and this has filtered down to the students in their development. It also enables large adjustments in clinical care with a very fine-tuning. As the recommendations for clinical care change, or as hospital/program policies change, we simply change the book. Case in point, as the JNC VII recommendations for hypertension changed, there was no need to have multiple lectures (with variable attendance); we simply changed the recommendations in the book. Imperceptibly, the clinical practice in our clinics adjusted accordingly.
 
The clinical wards can be a vast sea, especially in internal medicine where there are no boundaries for its knowledge domain. For this reason, I set aside two hours each Monday afternoon to sit in room 7150. It is an optional conference, sometimes attended by 30 students, sometimes attended by none. It is always a spontaneous discussion: whatever problems the students have on the wards, whatever did not quite make sense to them in a lecture, or perhaps a patient dilemma their team cannot decipher… this is what we discuss in this conference. I don’t claim to be the best internist at Tulane, but I do think it is important to role model this feature of the internist: everything is fair game, not just the lecture material I have prepared. I try to model this feature of internal medicine by keeping this time “uncanned” and spontaneous; whatever they bring to me, I will discuss to my limits. Then I will model the action of admitting what I do not know, and I model the practice of looking it up in the medical literature. I usually ask the students to do the looking up with me; engaging in the action solidifies the lesson.

And then there is my favorite teaching (coaching) exercise: attending on the wards. I could write a book (and currently I am) about the components of great ward-based teaching. For the sake of brevity, I’ll note the four most important principles.

The most important lesson in teaching on the wards is that clinical medicine is first and foremost about the patient. A student may pay astronomical amounts of money to attend medical school, but that does not entitle him to have the right to be in a patient’s room; it is a privilege to be there. As an attending, I may have logged thousands of hours in medical training, but does not give me the right to be in a patient’s room; it is a privilege to be there. And yet this lesson is increasingly being lost. I think it is a product of erroneously over-extending a correct concept from the pre-clinical years: evoking student opinion as to what would improve their educational experience. From repeatedly asking, “What do you want? What do you want?” comes the student’s mentality, “Medicine is about what I want.” While soliciting student opinion are just and valuable, over-extending the mentality leads to the assumption that students have a right to provide patient care, and this has created a sense of entitlement and self-righteousness. In the long run, both are disastrous to patient care. I try to offset this mentality, but it is not as easy as to bluntly tell the student “you don’t have a right to be here.” This would disenfranchise the student. The lesson must be learned subtly, and via actions and not words. Preserving the sanctity of the patient’s room is the first step to re-focusing the student physician (including myself) on the patient. My task is to show this to students in small, subtle actions such as knocking before entering, asking when would be a good time to return to his room (instead of showing up when it is convenient for me), delivering all patient care opinions as recommendations and not mandates, and respecting the patient’s wishes (and the patient) when he chooses not to follow my recommendations.

I teach also the importance of patient advocacy. Rhetoric will not cut it; it requires consistent role modeling for a student to learn the importance of advocating for a patient, whether that be a necessary surgery or procedure, or social work accommodations. Implicitly, I try to teach that the physician should not be too good for anything. Finding a nursing home bed for a patient is beneath my intellectual abilities, but not beneath my ethical and moral obligations to my patient. It is after all about the patient. I try to teach that medicine is not about what I personally find fun or exciting; it is about caring for my patients, in whatever way they need me to care for them.

I also teach the science of medicine, and I evoke the same principles of seeking understanding (through physiology), and growth (through evidence-based medicine) as in the other parts of my clinical teaching. I could expand about the specifics of what medical topics I teach on the wards, but it would take too much space and really it is not as important as the two lessons I try to teach noted above. Suffice to say, I believe that the noun in the phrase “humanistic doctor,” or “caring doctor,” or “professional doctor” is still “doctor.” Students have to learn the science of the craft; a patient seen in an ICU by a “caring doctor” who does not know how to treat his acid-base disorder would have been equally well-served by going to see his “caring priest.” I suspect the result would be the same. My goal on the wards is to deliver substance in addition to the intangibles. Science is taught by words and chalkboards; professionalism is taught by actions. Professionalism at its heart is professing who you are in what you do. The sentinel virtue is sincerity, since insincerity by definition is doing something different than whom you are. That said, sincerity is best conveyed by consistency of action. Therefore, professionalism is a product of consistent action, not words.

Year 4: Sub-Internships

The salient features of my fourth-year sub-internship teaching do not vary from that of third-year ward teaching (vida supra), save on key element. Medicine is about learning to make decisions; putting yourself on the line by “putting your nickel down” teaches you to assume responsibility for your actions. Once a student has assumed responsibility for his actions, he is much more likely to think about the consequences of his actions prior to making decisions. And this is a key component to the effective physician. Therefore, I push the fourth-year students a little harder during their sub-internship; I force them to make decisions, and I try to create an environment where decisions that result in adverse outcomes are ok. There is an art to this, and the art is knowing which wrong decisions will be meaningfully harmful to the patient, and which wrong decisions will be benign. In the first case, I must intervene to correct the decision before it is made; in the latter case, the student must have the latitude to learn from the mistake without overbearing intervention on my part.

Year 4: Advanced Internal Medicine

The Advanced Internal Medicine course is perhaps the favorite thing I do in my life. I devote four, month-long electives to this course. On average there are eight students that will select this elective. We spend an hour or two in the morning seeing patients together, and then two to three hours in the late afternoon sitting around a coffee-table discussing science, philosophy, history and the other humanities as they pertain to medicine. It is an Oxford model of teaching, and the discussions teach me as much about myself as I teach the students. The inspiration for many of my philosophical writings (Section 12) originate from these sessions.

Clinical Coaching Course (Teaching Teaching)

To make a big difference in the world, you must be exponential. Seeing one patient at a time with all of the correct methods will never be as powerful as training hundreds of physicians to care for their patients with all of the correct methods. This principle is the genesis of the Teaching Teaching Course (now called the Clinical Coaching Course) offered to fourth-year students in February. The month-long course contains many of the principle espoused above. It’s guiding principle, however, is that teaching is a performance sport. Like other performance sports (dancing, music, athletics) the skill cannot be obtained by listening to rhetoric and theory; it cannot be acquired through didactics. The skill is only developed through frequent practice. The outline of the course is attached in Section 7, though you will note that it is a comprised of morning discussion groups in which the principle(s) of the day are delivered, and then afternoon teaching practice sessions in which the principle(s) of the day are refined. The back half of the course is real-time teaching, with a secondary goal of developing the ability to “shift gears” to provide content/skills appropriate to different learner levels (note the range of students being taught by the fourth-years: first-year students through residents).

There is also a hidden agenda nestled within the Clinical Coaching month. Many of the topics the student’s teach (the Clinical Problem Solving Exercise, the Preparation for the Wards Seminar) are skills important for their future performance (i.e., clinical reasoning, oral case presentations, writing good admission notes, etc.). The goal is to take advantage of cognitive dissonance: if a student espouses as part of her teaching the importance of doing these skills correctly, it makes it much difficult for her to practice these skills incorrectly in her practice. Instead of wrestling with the dissonance between what is espoused and what is done, it is easier for her to do the skills correctly. In this way, the Clinical Coaching month is the last lesson in consolidating a long progression of teaching the key skills of clinical performance.

Internship/Residency

By now, it should be clear that the goal of my coaching strategy is to prepare students for clinical performance on the wards and in their clinics. Residency is the last opportunity to ensure optimal clinical performance prior to the physician beginning her clinical career. The work I have invested in the Tulane residency is beyond the scope of this narrative, but a few salient points are worth mentioning.

The core competencies are correct. My strategy has been to embrace the core competencies and work to empower the residents with the skills necessary not only to satisfy the ACGME, but also to create academic leaders.

Medical Knowledge

Lectures: Friday School

The teaching logs (Section 3) speak to the number of hours I have spent with medical lectures to the residents. While successful, these didactic lectures were still passive. To augment the active form of learning, the lectures in the residency were disbanded, and replaced with the Friday School Curriculum (See Section 7). The success of this curriculu (see Section 6) has been so robust, that 10 other residency programs at Tulane have made the switch to this model of education, as well as 15 other institutions nationwide.

Morning Report

I attend morning report at Charity Hospital each day. As opposed to most training programs, I do not use morning report as a venue for a mini-didactic lecture or a forum for presenting the most fascinating case on the wards. Rather, I have re-designed this conference at Tulane such that the chief resident facilitates, but does not dominate the discussion. Residents are asked, one at a time, to provide their assessment of the case (i.e., differential diagnosis and pre-test probabilities for each diagnosis) and then to clinically reason their way through the case. The session is about how the residents grapple with the case, and the emphasis is on evaluating and correcting their clinical reasoning, not upon the specific knowledge points of the case. It is active learning that drives this conference, and it is from active participation that residents retain the lessons they learn here.

Patient Care

I attend on the wards at least five months a year. My approach to attending as been discussed above (vida supra), and these same teaching principles I try to fulfill for the residents.

Interpersonal and Communication Skills

In June and July I train the residents on how to teach students the art of the oral case presentation and the admission note, and how to use clinical reasoning (Bayesian theory) to establish both. We spend about six hours together learning these skills, with the last two hours of the mini-course being devoted to how to correct common deficits in oral case presentations. We devote this time because 80% of the preceptors in Clinical Diagnosis will come from the internal medicine residency, and certainly all of the internal medicine residents will be on the front lines (on the wards) teaching students these skills. The implicit and hidden objective is that by teaching residents how to teach these skills, they internalize the principles of the skill itself. The goal is that their interpersonal and communication skills will also improve.

Professionalism

I apply the same principles of teaching professionalism (see the discussion above) in my interactions with the residents as I do with the students.

Systems of Care and Practice Based Learning

I am the primary investigator on two RWJ grants: ACT I and ACT III. Both grants are designed to teach systems of care and quality improvement as part of residency training. I restructured the residency into four firms to enable this curriculum. Each firm has a firm leader (chief resident) and a firm faculty. Each firm goes through the QI kit (Section 8 Supplement) in designing their firm’s quality improvement project.

I also attend each of the monthly journal club sessions and teach the evidence-based curriculum as part of the core-curriculum series.

Residency Program in General

This section is short, but not for lack of topics upon which to comment. A full narrative about the residency program would require numerous pages. Perhaps the flow diagram at the end of this section will give you an idea of how much effort has been extended here, and how complex this task of graduate medical education really is.

I will note the time that I devote to mentoring residents in their case presentations and scholarly work. I see Tulane’s Internal Medicine Residency as being a smaller part of Tulane’s vision to be a nationally renowned academic center whose primary mission is develop future academic leaders. It has been a priority to get the Tulane internal medicine residents and students to national meetings so that they can see the standard for academic research, and can begin to be part of the national scientific discussion. Section 16 speaks to this mentorship and the success with which we have had. Make no mistake, each vignette accepted represents hours of work I have devoted to teaching the resident not only how to get the vignette or abstract accepted, but also the skills of scholarly research and medical writing. There are numerous other vignettes/abstracts from the internal medicine residency not represented on this list because I did not co-author those. The list not presented is the one I am most proud of, however, since the mentors for those vignettes (i.e., the senior authors) are the senior residents I once taught how to write abstracts, who are now teaching the junior residents the same skills. This is exponential teaching.

Faculty Development/ Hospitalists

To ensure student and resident performance in their clinical care, it is important that other faculty are brought together as a team and empowered to provide similar coaching expertise. To this end, I wrote and submitted the proposal that provides 1.2 million dollars from the state each year to pay for teaching hospitalists at Charity Hospital. I am also responsible for the regular faculty development seminars that train these physicians in the education principles espoused in this portfolio.
I am responsible for the Department of Medicine’s grand round curriculum, a weekly conference focusing upon clinical reasoning, state of the art standard of clinical care principles, and emerging scientific advancements.

Remediation

As my mentor one told me, “Anyone can teach the good ones… but each and every student will eventually care for the same number of lives. Caring for the struggling student is the most important thing you can do.” I designed and implemented the COUGAR curriculum at UCSF in 1999, and have continued here at Tulane to the present day. COUGAR, The Curriculum to Observe Underachievers and Give Assisted Remediation has taken care of 71 struggling students or residents, and 63 of these have been fully restored to successful careers. The details of COUGAR are in Section 7.

National Education

I spend considerable time with national speaking engagements and workshops. The content in this narrative is my philosophy on medical education. I think my hypotheses are correct, but I also recognize that my approach may be incorrect; the hypotheses exist in their current form because of multiple past errors and with subsequent adjustments. And just because I believe in something does not make it true. Like all science, what is thought to be true should be held up for inspection and criticism. The national venues of APDIM, ACP, SHM, SGIM, CDIM and visiting professorships are the forum for this inspection and criticism (Section 10). This is also the driving force for my scholarship in medical education. By publishing my ideas, I happily invite criticism. It is from this criticism that the ideas are modified and thus better approximate the truth. As Mortimer Adler noted in his Ten Philosophical Mistakes: the primary philosophical mistake is to believe that what is true for you may not be true for me. Truth is truth, independent of our opinions about it. Only by critical analysis of hypothesis do we better approximate the truth. This applies to medical education as much as it does to bench science.

I am on the Board of Governors for the Society of Hospital Medicine (SHM) and the Board of Governors for the Association of Program Directors in Internal Medicine (APDIM). In both roles, my objective has been to seek ways to make exponential improvements in the field of medical education. There have been numerous other positions (See Section 10), all with the same goal.