1 P E R S P E C T I V E Freedom from the Tyranny of Choice stance, recognizing our tendency of-life conversations should be humously, in 1980, about what - to shy away from death, Aaron he sought from his own physi treated like any other competency, such as placing a central line or Waxman, an intensivist at Brigham cians at the end of life. He wrote, and Women’s Hospital, insists that “A physician who merely spreads choosing appropriate antibiotics an array of vendibles in front of for pneumonia. An attending phy - each conversation include the the patient and then says, ‘Go sician should model the skill, then words “death,” “dying,” and ahead and choose, it’s your life,’ watch trainees and offer feed “dead.” Rather than try to dis - - - - . . . does not warrant the some - suade patients from choosing re back. Prognostication should sim ilarly become a required skill. For - suscitative measures by stressing what tarnished but still distin their potential brutality, Waxman instance, every initial admission guished title of doctor.” - of a seriously ill patient should Disclosure forms provided by the authors chooses to focus on ways the phy - are available with the full text of this arti - - sician can help to promote com include an assessment of prog cle at NEJM.org. fort. Through his example, he nosis alongside the plan for each Drs. Lamas and Rosenbaum are editorial teaches residents that patient organ system. Assessments should . Journal fellows at the autonomy is not synonymous with be discussed on rounds, and resi - Siddiqui MF, Holley JL. Residents’ prac endless choice. - 1. dents should be required to follow tices and perceptions about do not resusci - These conversations won’t get up to determine their accuracy. - tate orders and pronouncing death: an op - Of course, leading these con - any easier. The population is ag portunity for clinical training. Am J Hosp Palliat Care 2011;28:94-7. versations requires some skills ing. Hospitalists have assumed the 2. - Deep KS, Griffith CH, Wilson JF. Discuss that are difficult to teach, such care of patients who would once ing preferences for cardiopulmonary resus - have been followed by their long- as intuiting the responses of pa - citation: what do resident physicians and their hospitalized patients think was decided? time physicians. Work-hour reform tients and families. Nevertheless, Patient Educ Couns 2008;72:20-5. - Kenneth Prager, director of clini - increasingly erodes residents’ re Temel JS, Greer JA, Admane S, et al. Code 3. lationships with inpatients. And cal ethics at Columbia University - status documentation in the outpatient elec - tronic medical records of patients with meta with medical advances such as Medical Center, says education re - static cancer. J Gen Intern Med 2010;25: mains imperative. He categorizes extracorporeal membrane oxygen - 150-3. trainees into three groups: natu - ation, ventricular assist devices, 4. - Anderson WG, Chase R, Pantilat SZ, Tul sky JA, Auerbach AD. Code status discus - - and transplantation, there’s al rally good communicators, poor - sions between attending hospitalist physi most always something else we communicators, and a middle cians and medical patients at hospital could offer. third who simply need proper admission. J Gen Intern Med 2011;26:359-66. Franz Ingelfinger, a former ed - instruction. 5. Heyland DK, Tranmer J, O’Callaghan CJ, - Gafni A. The seriously ill hospitalized pa who died of itor of the Some attendings model these Journal tient: preferred role in end-of-life decision conversations for their teams and - esophageal cancer, wrote an es making? J Crit Care 2003;18:3-10. offer tangible advice. For in - say that the Journal - published post Copyright © 2012 Massachusetts Medical Society. B E C O MING A P H Y S I C I A N Lecture Halls without Lectures — A Proposal for Medical Education Charles G. Prober, M.D., and Chip Heath, Ph.D. It’s time to change the way we he last substantive reform in - methods have evolved, and un - medical student education fol precedented opportunities for tech - educate doctors. Since the hours T lowed the Flexner Report, which - available in a day have not in nological support of learners have - - was written in 1910. In the ensu creased to accommodate the ex become available. Yet students are being taught roughly the same - ing 100 years, the volume of med panded medical canon, we have way they were taught when the ical knowledge has exploded, the only one realistic alternative: make Wright brothers were tinkering at complexity of the health care better use of our students’ time. system has grown, pedagogical We believe that medical education Kitty Hawk. 1657 2012 n engl j med nejm.org may 3 366;18 , The New England Journal of Medicine Downloaded from nejm.org at CONSELLERIA DE SANIDADE SERGAS on May 3, 2012. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved.
2 P E R S P E C T I V E Lecture Halls without Lectures the form of television shows like ing simulation exercises. Students can be improved without increas - and would welcome more opportuni - House Grey’s Anatomy ing the time it takes to earn a or from - medical degree, if we make les ties for case-based, problem- the New York Times “Diagnosis” - based, and team-based exercises sons “stickier” (more comprehen column. When possible, we should seize that curiosity — the perfect sible and memorable) and embrace — strategies that activate prior fuel for learning. a learning strategy that is self- knowledge. Teachers would be Messages also become stickier able to actually teach, rather than paced and mastery-based and merely make speeches. when they come in the form of a boosts engagement. Digital media make video lec Research has elucidated the fac - - - story that elicits emotion in read 1 tures relatively easy to create, offer For tors that make ideas sticky. ers or listeners. Patients’ stories are what make the acquisition of instance, messages are stickier flexibility so that students can medical knowledge compelling. watch at their own pace and on when they are unexpected enough to capture our curiosity. their own schedule, and are pop- They serve as the scaffolding on Consider this excerpt from a re ular with learners. For example, - which facts and concepts can be the Khan Academy, a nonprofit - cent “Case Records of the Massa organized and reinforced. As Sir chusetts General Hospital”: “A William Osler aptly said, “He who organization that offers online studies medicine without books video lessons and exercises on ele 37-year-old man was admitted to - this hospital because of muscle sails an uncharted sea, but he mentary and high school topics, who studies medicine without pa - pain and weakness. The patient - allows students to gain proficien tients does not go to sea at all.” cy in core academic concepts at had been well until the evening their own pace. If such a model Yet conversations with medical before admission, when mild dif - students about the first-year fuse myalgias developed. He awoke were applied to medical school, - medical curriculum reveal that in the morning with diffuse mus class time would be freed up for higher-order and more interactive about half of lectures proceed cle cramps and intense pain in without even the briefest exam lessons. Teachers could track each . . . On arising to go his legs. - to the bathroom, he felt unsteady student’s progress and use that ple involving patients. - and had difficulty walking. After Attention to stickiness would knowledge to inform focused, cus - make medical school lectures tomized interactions with small he returned to bed, diffuse mus more engaging and memorable, groups of students. Recently, this cle pain persisted, with weakness but they would still be lectures. - approach was embraced by a pub in his arms and legs and numb- - We think a more radical and im - lic school district and several char ness in his legs; he was unable to 2 portant strategy is to move those ter schools in Silicon Valley, and arise again.” Do you want to learn more? experience with this educational lectures outside the lecture hall and to use class time for more model has grown to encompass That’s the power of the clinical scenario. The case’s discussant a broad range of content areas active learning. reflects on the differential diag and learners. The Khan Academy For most of the 20th century, - nosis that might explain this acute has produced more than 2700 lectures provided an efficient way onset of weakness and pain, in videos that are viewed monthly by - to transfer knowledge. But in an era with a perfect video-delivery cluding inflammatory, infectious, more than 3.5 million students toxic, metabolic, and autoimmune platform — one that serves up who perform more than 2 million processes. A single such case could billions of YouTube views and mil online exercises each day. - lions of TED Talks on such - This year, our core biochemis serve as the lead-in to multiple medical school topics that might things as technology, entertain try course at Stanford Medical - otherwise seem dry and routine. School was redesigned following ment, and design — why would The goal is to time the story anyone waste precious class time - this model; rather than a stan - to captivate learners and under - dard lecture-based format, the in - on a lecture? We propose em structors provided short online score the relevance of knowledge bracing a flipped-classroom mod - they’ve recently acquired or that’s el, in which students absorb an presentations. Class time was used about to be conveyed. Medical edu for interactive discussions of clin instructor’s lecture in a digital - - ical vignettes highlighting the bio - cators might take a cue from pop format as homework, freeing up culture: even laypeople love med - - chemical bases of various diseases. class time for a focus on applica - The proportion of student course ical mysteries, imbibing them in tions, including emotion-provok 1658 2012 may 3 , nejm.org n engl j med 366;18 The New England Journal of Medicine Downloaded from nejm.org at CONSELLERIA DE SANIDADE SERGAS on May 3, 2012. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved.
3 P E R S P E C T I V E Lecture Halls without Lectures sary in the comfort of their per reviews that were positive in - teaching assistants, students grap - - pled with real physics problems sonal learning space. Knowledge creased substantially from the previous year. And the percentage as they might be encountered by a acquisition is verified by repeated of students who attended class practicing physicist. The students low-stakes quizzes. Then, in class, in the second, active-learning sec - shot up from about 30% to 80% the students participate in a dis - - — even though class attendance cussion that includes a child with tion were more engaged (as as was optional. sessed by their course ratings) and a metabolic disease, his or her more likely to attend class, and parents, the treating clinician, Evidence is accruing that on - their scores on a course test aver and the biochemistry professor. line instruction is effective and - aged 74%, as compared with 41% scalable. For example, Stanford’s The relevant biochemistry — so computer science department has dry on the page of a textbook — among students in the traditional - shifted several courses to instruc lecture section. A meta-analysis comes to life. The lesson sticks. published by the Department of Disclosure forms provided by the authors tion using 10-to-15-minute video are available with the full text of this article Education has concluded that “on segments with embedded quizzes at NEJM.org. to engage learners and test their - average, students in online learn comprehension. Professors use ing conditions performed mod - From the Stanford School of Medicine class time to challenge students (C.G.P.) and the Stanford Graduate School estly better than those receiving of Business (C.H.), Stanford University, face-to-face instruction,” with with hands-on exercises, and class Stanford, CA. larger effects if the online learn - attendance has increased substan - - ing was combined with face-to- tially. Off campus, three comput Heath C, Heath D. Made to stick: why 1. 4 er science courses, offered free, face instruction. some ideas survive and others die. New York: Random House, 2007. That’s the vision that we want have been viewed by more than Case Records of the Massachusetts Gen 2. - to chase: education that wrings 350,000 enrollees from around eral Hospital (Case 4-2012). N Engl J Med more value out of the unyielding 2012;366:553-60. the world. 3. Deslauriers L, Schelew E, Wieman C. Im - Freeing up class time does asset of time. There are limits to proved learning in a large-enrollment physics the amount we can lengthen class seem to make a difference. In a class. Science 2011;332:862-4. recent study, researchers com periods and the additional home - 4. Evaluation of evidence-based practices - - in online learning: a meta-analysis and re - pared two sections of an under work we can assign, but we can view of online learning studies. Washing - use our limited time in ways that graduate physics course that had ton, DC: Department of Education, Office 3 The first sec - boost engagement and retention. - a large enrollment. of Planning, Evaluation, and Policy Devel opment, 2010 (http://www2.ed.gov/rschstat/ tion used the traditional lecture - Imagine first-year medical stu eval/tech/evidence-based-practices/finalreport - dents learning critical biochemi model and was taught by a Nobel .pdf ). cal pathways by watching short Prize–winning physicist. In the Copyright © 2012 Massachusetts Medical Society. - second section, which was led by videos as many times as neces Looking beyond Translation — Integrating Clinical Research with Medical Practice Annetine C. Gelijns, Ph.D., and Sherine E. Gabriel, M.D. - pediatric cancer specialists. Nine tion in the clinical research pro - ne area of amazing recent O - ty percent of U.S. children with medical advances has been cess. The robust clinical trial en - - childhood cancers, for which sur cancer receive care in centers af terprise for this patient population vival rates have quadrupled over filiated with this network, and may offer a model for improving outcomes in other age groups, the past four decades and now more than 60% of children with cancer are enrolled in clinical exceed 80%. This progress has populations, and conditions. The success stems largely from the trials. This engagement permits been driven not only by the in - - Children’s Oncology Group, a co troduction of novel therapies but - rapid evaluation of new thera operative clinical research group also by the remarkable level of pies, including delineation of ap- that includes more than 5000 U.S. - patient and physician participa propriate subpopulations, which 1659 3 , 2012 n engl j med 366;18 nejm.org may The New England Journal of Medicine Downloaded from nejm.org at CONSELLERIA DE SANIDADE SERGAS on May 3, 2012. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved.
1 Conservation Biology for All EDITED BY : Navjot S. Sodhi AND * Department of Department of Biological Sciences, National University of Singapore Organismic and Evolutionary Biology, Harvard Universi...More info »