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Future Medical Education

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Presentation by Dr. Frank Lau to Dartmouth Course "Engineering Sciences 13: Redesigning Healthcare: Problems and Opportunities" taught by Professors/Drs. Joe Rosen and Peter Robbie.

More information on the course
http://www.dartmouth.edu/~engs13/syllabus/index.html

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Future Medical Education

  1. 1. Future Medical Education<br />Frank Lau, MD<br />11/4/2010<br />
  2. 2. Undergraduate education (“Premeds”)<br />4 years<br />MCAT Exam<br />Medical School<br />4 years<br />USMLE Step I & II Exams<br />Internship/Residency<br />3-4 years<br />Specialty Licensing “Boards”<br />Specialty/Subspecialty Fellowship<br />1-3 years<br />Structure of U.S. Medical Education<br />11+ years…this a BIG topic!<br />
  3. 3. Med Ed: A Subject of Intense Scrutiny, Research, & Opinion<br />
  4. 4. The Major Concerns<br />From 1984!<br />But still relevant…<br />
  5. 5. Emphasize skills/values/attitudes just as much as knowledge acquisition<br /> the amount of factual information students must memorize<br />Better delineate the skills needed to enter residency<br />Update MedEd per changes in Healthcare<br />Technology, advances in knowledge, systems, demographics, etc.<br />Promote health & prevent disease<br />Don’t just treat after patients get sick<br />Conclusion #1: Purposes of a General Professional Education<br />
  6. 6. Identify students who can learn independently and encourage that<br />Help students who don’t have this skillset<br />Reduce scheduled time<br />40% of US schools require 40 hrs classtime per week  equates to 120 hrs of “schoolwork” per week<br />Cut lecture time in half<br />Promote active learning, problem solving<br />Less information absorption<br />Designate academic units to lead schools in applying IT/CS to education<br />Conclusion #3: Acquiring Learning Skills<br />
  7. 7. More Recent Developments<br />Teaching patient shortages<br />Teacher shortages<br />Conflicting systems<br />Financial disincentives for education<br />
  8. 8. “In the scenario we’ve painted, there is no apparent help to come to our aid and a compelling need to ramp up production of medical graduates to address physician shortages. We cannot continue the practice of expecting faculty to “work harder and longer” as, for the most part, they are already overextended. Further, as physician shortages take hold, we can expect to see depletions of clinical teachers, so we will need to find alternatives to maintain a minimum number of educators. We can no longer expect that clinical experiences will automatically provide students with all that they need to make progress toward becoming physicians.”<br />More Recent Developments<br />
  9. 9. High Impact Solutions<br />Knowledge Maintenance Systems<br />Point-of-care Resources<br />Digital Simulators<br />KMS<br />PoC<br />Sim<br />Centralized, National Resources<br />
  10. 10. Solutions vs. Problems<br /> the amount of factual information students must memorize<br />Update M.D. knowledge per changes in healthcare<br />Reduce scheduled time<br />Cut lecture time in half<br />Lead schools in applying IT/CS to education<br />Teaching patient shortages<br />Teacher shortages<br />Conflicting priorities (patient safety vs. clinical productivity vs. education)<br />Financial disincentives for education<br />KMS<br />PoC<br />Sim<br />KMS<br />PoC<br />KMS<br />PoC<br />Sim<br />KMS<br />PoC<br />Sim<br />PoC<br />Centralized!<br />PoC<br />Sim<br />
  11. 11. The “Holy Grail”<br />
  12. 12. The “Holy Grail”<br />2. Update M.D. knowledge per changes in healthcare<br />KMS<br />PoC<br />Sim<br />Why is this critical?<br />80,000 clinical trials conducted annually<br />>400,000 human medicine articles published in 2009<br />UpToDate releases new versions of its manually-curated online textbook every 4 months<br />Reliable information source feeds into every aspect of medical education<br />
  13. 13. The “Holy Grail”<br />2. Update M.D. knowledge per changes in healthcare<br />KMS<br />PoC<br />Sim<br />What would this look like?<br />Database of medical topics<br />Automated meta-analysis of published research<br />Automated quality assessment: design, metrics, statistics<br />Remove outdated / incorrect knowledge<br />10 years after vitamin E research was disproven, >50% of articles favorably cited that research.<br />
  14. 14. Point of Care Resources<br />
  15. 15. Example Case:<br />A patient goes to see her internist because she has eyebrow loss and she wants a doc’s opinion regarding eyebrow transplants.<br />This is a very specific problem!<br />Current options:<br />Refer patient to a specialist<br />Ask patient to schedule a second appt, review literature in the meantime<br />“Quickly” read an online resource<br />Make something up (e.g. “No one does transplants.”)<br />Point of Care Resources<br />PoC<br />
  16. 16. Point of Care Resources<br />PoC<br />
  17. 17. <ul><li>“Quickly” read an online resource</li></ul>Point of Care Resources<br />PoC<br />
  18. 18. Point of Care Resources<br />PoC<br />
  19. 19. Point of Care Resources<br />PoC<br />
  20. 20. Point of Care Resources<br />PoC<br />
  21. 21. Point of Care Resources<br />PoC<br />
  22. 22. But…eyebrow transplants ARE being done.<br />Also: there’s an ICD9 code for this problem.<br />This code is needed for documentation & billing.<br />Link knowledge sources to the same code, and embed in the Electronic Medical Record.<br />Point of Care Resources<br />PoC<br />
  23. 23. Point of Care Resources<br />PoC<br />Link knowledge sources to the same code, and embed in the Electronic Medical Record.<br />Ms. X is a 27-year-old hairdresser who comes in with questions regarding eyebrow transplantation for the treatment of trichotillomania. She is otherwise healthy…<br />Lookup:<br /><ul><li>eyebrow transplantation
  24. 24. trichotillomania</li></li></ul><li>Impact of PoC Resources<br />PoC<br />
  25. 25. Simulations<br />
  26. 26. Static: Interactive Medical Cases<br />http://www.nejm.org/doi/full/10.1056/NEJMimc1004455<br />Interactive: Hyper-specialized<br />Simulations: Current Tech<br />Sim<br />
  27. 27. Mannequin-based<br />Simulations: Current Tech<br />Sim<br />
  28. 28. Digital Simulations in Medicine: Years behind other industries<br />Simulations: Current Tech<br />Sim<br />“Featuring 45 patients…”<br />
  29. 29. Framework for generating scenarios<br />Automatically create patient details while allowing for customization<br />Options to allow for varying degrees real-world complications<br />“Natural language” meta-programming? Think Ruby on Rails, etc.<br />Intuitive GUI for generating cases<br />Natural workflow for trainees to go through the cases<br />Simulations: Target Features<br />Sim<br />
  30. 30. Open-ended<br />Networked to allow for team training<br />Scalable graphics<br />Compatible with haptics / peripherals<br />Motion-sensing (Wii, Kinect, etc)<br />Simulations: Target Features<br />Sim<br />
  31. 31. Gunshot wound to the neck<br />Framework could automatically generate:<br />Specific anatomical location of injury  structures injured (carotid, jugular, muscle only, nerves)<br />Patient age & medical comorbidities what impact on physiology & responsiveness to resuscitation<br />Or, these could be customized by the educator<br />Simulations: Example<br />Sim<br />
  32. 32. Gunshot wound to the neck<br />Scale to trainee level<br />1st med student – Straightforward injury (only the carotid is injured)<br />3rd year med student – Nurses unable to start IVs; place a central line<br />Surgery / ED resident – Bullet lodged in cervical spine, limiting options for intubation<br />Networked<br />Proctor can modify scenario on-the-fly<br />Team-based practice<br />Simulations: Example<br />Sim<br />
  33. 33. Impact of Simulation<br />
  34. 34. Knowledge Maintenance Systems<br />Disclaimer: I am a co-founder of a company that works in this space.<br />
  35. 35. Traditional Learning Process<br />KMS<br />Knowledge<br />Time<br />Lecture<br />Cram for Test<br />Cram for Bigger Test<br />
  36. 36. KMS<br />
  37. 37. KMS<br />
  38. 38. The Challenge Persists for Residents<br />Resuscitation, July 2009<br />70 Johns Hopkins pediatric residents<br />66% failed to start timely CPR (basic life support)<br />95% of the residents had received this level of training<br />83% made errors during defibrillation (shocking the patient)<br />80% of the residents had been trained in defibrillation<br />More years of training did not improve physician performance<br />KMS<br />
  39. 39. The Challenge Persists for Attending Physicians<br />Journal of Trauma, June 1996<br />60 experienced, practicing physicianstook the standard Advanced Trauma Life Support course, followed by an examination<br />National course for managing traumas (car accidents, gunshots, stab wounds, etc)<br />Immediate testing: 86% average score<br />6 months later, 50% failed<br />13 years after this study, no novel approaches to learning and retaining medical knowledge<br />KMS<br />Basic, critical knowledge is routinely forgotten, <br />even by experienced specialists.<br />
  40. 40. Spaced Learning<br />In 1913, Ebbinghaus discovered that the best time to review something was just before it was forgotten<br />Minimizes the amount of time spent learning<br />Minimizes the number of times the same material must be relearned<br />KMS<br />
  41. 41. Basic Research on Spaced Learning<br />The molecular mechanism behind Spaced Learning is an active area of research<br />Cell, October 2009. Cold Spring Harbor & Mount Sinai School of Medicine<br />The Phosphatase SHP2 Regulates the Spacing Effect for Long-Term Memory Induction<br />Journal of Neuroscience, August 2009. McGill University<br />PKC Differentially Translocates during Spaced and Massed Training in Alypsia<br />Neuron, December 2006. Baylor College of Medicine<br />Drosophila Mushroom Body Neurons Form a Branch-Specific, Long-Term Cellular Memory Trace after Spaced Olfactory Conditioning<br />KMS<br />
  42. 42. Knowledge Decay can be predicted<br />Knowledge Retention can be enhanced:<br />1) Efficiently<br />2) So that users never forget the material they’ve learned<br />The Point<br />KMS<br />
  43. 43. KMS<br />
  44. 44. KMS<br />49.1% performance gain<br />
  45. 45. Impact of KMS<br />KMS<br />
  46. 46. Parting Thoughts<br />
  47. 47. Economies of scale<br />Market capture<br />Transferable technologies / IP<br />Size of medical test prep market:<br />$91 million annually<br />Number of U.S. medical students:<br />80,000 per year<br />Tuition fees for medical students:<br />In-state $21,500<br />Out-of-state / private $42,500<br />Minimum market: $2 billion per year<br />
  48. 48. Dr. Joe Rosen<br />Dartmouth School of Engineering<br />Gunner Training<br />Acknowledgements<br />Contact<br /><ul><li>Frank Lau, MD
  49. 49. frank@gunnertraining.com</li>

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