The in-Training Editors-in-Chief, Nihaal Mehta (NM) and Amelia Mackarey (AM), talked to Dr. Dustyn Williams (DW) and Jamie Fitch (JF), co-founders of OnlineMedEd — one of the most widely-used educational resources by medical students around the world — and two leading figures in shaping medical education. The conversation ranged from OnlineMedEd as a learning platform to Dustyn’s and Jamie’s philosophies on teaching and the future of medical student education.
You can also read parts one, two, three, and four of this interview. Here, in the fifth and final installment, we talk why, even though EMRs have been “devastating” for medical education, we should stay optimistic about the role of information technology in health care, how medical knowledge is becoming less important in being a successful physician and the future of OnlineMedEd.
JF: Medicine’s experiential, really college in general is. Schools are moving to an advanced trade school [model]. They’re teaching you the skills you need. The medical knowledge, we can teach you — honestly, we’re an A.I.-assisted world now. When I go to the doctor and tell them, “X, Y, Z,” I see them step out for a second, open their phones, Google something and tell me what I already knew because I had just done the same thing. With this realization, it is about everything else. The medical knowledge can be pushed to the side — it can be given through OnlineMedEd.
DW: Talking about EMRs [electronic medical records], I see the role of the physician … [it’s] changing. People go into medicine wanting the one-on-one experience with the patient. I don’t think that’s what physicians are going to be used for. We’re going to be used for leadership roles, the ones who come up with the plan, who interpret the research. We’re going to have our hands controlling large teams: PAs, NPs, mid-level providers who can follow the algorithms and feed back the difficult patients to the physicians. This is totally my opinion — I have no evidence for this. I do believe the role of the physician is going to become more of a leader and supervisor. They’re still going to see patients, but they’re be more of the decision-makers, not necessarily the algorithm-carrier-outers.
JF: Whenever you have new technology, there’s always a painful transition period. We’re in that right now with EMRs and a lot of the telehealth stuff. But these things are improving. A.I. is getting really good. You think about Alexa — every six months it gets better. There are companies working on, as you’re doing your H&P, recording all of that into EMRs automatically. Telehealth — home monitoring of glucose, of hypertension. Technologies are still in their infancy. It’s a 30-, 40-, 50-year process. We’re only five or ten years into this transition. It sucks that we’re in the middle of that right now, so it really hurts everyone involved. But, I think going forward these problems are going to be solved, and we’ll get more to Dustyn’s model where you see the team leader who’s overseeing everything, almost like a mini-CEO within medical care.
NM: I would definitely agree, we’re in a transition period in terms of using technology, both in medicine and medical education.
From what I’ve heard, 20 or 30 years ago, in a clerkship the medical school would have been responsible for teaching the students everything. You would have been taught a lot more by residents during the day.
My experience now is that we’re in an in-between phase. Students spend 12 to 14-hour days at the hospital, and, after rounding with the team in the morning, the rest of the day the team is writing notes and the student is watching videos or reading a textbook. Clerkships are still trying to figure out how to get that experiential learning while also allowing students to learn material. If those two things can be reconciled, that could be exciting.
DW: I tell the students, they’re supposed to see two patients a day on medicine and we’re in the emergency room every other day. The students are always flabbergasted — they come from Miami where they’ve shadowed for six months, and they come to my clerkship where, day one, they’re doing an H&P themselves. What happens is they don’t know how to do it. I created a clinical series that I send to all the students — for example, how to do an H&P. I expect them coming in to own the patient. I actually encourage students to write paper orders. They’re not allowed to write orders in the computer. They have to write them out and show them to the resident, like I used to do as a medical student.
EMRs have been devastating — residents spend 60% of their time in front of the computer writing their note, where it used to be five minutes in shorthand. We have not made things more efficient. We’ve made things worse for physicians in practice.
What happens is students show up as a sub-I, and they have to spend the year catching up to where they were supposed to be. They come to residency less prepared than they should be, because the experience doesn’t start early enough in medical school.
I have a feeling we can change that. Do all of Step 1 in a year — just watch all of OnlineMedEd and take the test. Now you can start clinicals a year earlier. That’s a crude way of doing it but that’s one example. Making the class time more efficient makes the experience time higher quality, even it f there’s less of it. Only go from 7 a.m. to noon if they write notes the rest of the day. You should leave and go do something else!
JF: A lot of that change is already happening. Enough schools have now switched to this one-year model for the basic sciences. If they can show success over three or four years, a lot of schools will follow suit.
NM: I would agree it’s a question of efficiency. Often I hear from older attendings that, anecdotally, residents are coming out less prepared. The scapegoat automatically is work-hour restrictions: “We spend 48 hours in the hospital straight, and if they did that too they would see twice as much and be more prepared.”
I would agree it’s a question also of efficiency and that starts in medical school. You don’t need to be spending more hours there if those hours aren’t productive. It’s a question of, let’s get the highest quality education in the time you can. I think there can be improvements in terms of the density of learning.
DW: The environment is changing. Particularly the clinical experiences are not changing with it. It’s not their fault because it’s difficult to create a solution. I think it’ll evolve and it’ll happen, but right now is not a great time to be a medical student.
NM: What’s next for OnlineMedEd?
JF: OnlineMedEd is growing in so many ways — we love to talk about this. The spectrum of being a doctor from when you start as a pre-med all the way until you die, we would like to cover. We are making really good gains in both directions. We are primarily for third and fourth year right now, and we also have that first year of residency pretty well covered. We’re working on some CME [continuing medical education]-related things — nothing formal to announce there, yet. We’re working on the basic sciences. What we’re really excited about is we started the site for medical students. We quickly realized it’s not just medical students who need the foundation, so we have PAs, NPs, PharmDs, among many others. We’ve recently launched a PA version of the website. It’s mostly the same with a few extra lectures. It has the ability to get CME credits for them. We’re working on that for NPs. And we’ve been working with some pharmacists on how our curriculum has helped within their context.
Health care’s a big field. There’s 18 million employed within it. We’re looking at what else we can do in nursing or even at the tech level. We’re looking at taking the lessons we’ve learned here and applying them to other areas of adult learning. We’re starting with spots that are still relevant to our audience so we’re working with a nutritional biochemist right now, who filmed a video series, “Nutrition for Doctors.” We feel that nutrition is often overlooked.
DW: And not vitamins or glucose absorption, but how do you feed your patients based on their disease?
JF: Exactly. And then we’re working with a leadership and executive management person who works with Fortune 10 companies. This goes back to seeing where medicine’s going — we want to create better doctors as people, as leaders. We’re going to take some of this content that’s relevant to people at startups, companies in tech, Fortune 500, et cetera, and take it to medicine. Give people the opportunity to understand what being a leader really means. When you’re placed in this position, you’ve earned it a different way — you’ve gone through school — but you haven’t actually proven you can lead a team of twelve. It can be daunting the first day when you have people reporting to you, to know how to manage those people and know what makes them tick.
DW: And that’s just for 2018!