Resonance is a student-run podcast aimed at showcasing the science at Baylor through the eyes of young professionals. Each episode is written and recorded by students who have a passion for research and the medical community. Guests on the show include both clinical and basic science research faculty who are experts in their fields.
Technology and the Future of Medical Education, featuring Drs. Anoop Agrawal and M. Tyson Pillow - Part 2
Erik: And we're here.
Brandon: We are here.
Erik: This is the Baylor College of Medicine Resonance Podcast. I am one of your hosts, Erik Anderson.
Brandon: And I am Brandon Garcia, another host.
Karl: And I'm Karl Lundin. I was the writer for this episode.
Erik: Yeah, and so we're gonna be picking up off of our previous episode. This is a two-part series if you will on medical education, and so if you haven't heard the first part, I urge you to go listen to that now. Karl, would you want to give us a little summary of everything?
Karl: Yeah, so basically we just talked to Dr. Tyson Pillow and Dr. Anoop Agrawal about their own experiences here at Baylor College of Medicine. We went over some sort of like education theory, a few educational models they like to use and apply here at Baylor, and also we talked about some exciting things they've been doing sort of conducting courses on this topic of medical education and technology. And now in the second half we're gonna kind of go into some more in-depth discussion on application, on potential changes that some of these technological advances might bring to Baylor or that they would like to see, or just kind of some far-out interesting ideas about how this stuff might alter medical school education in the not-too-distant future. And then we'll also kind of hone in and talk about specialty-specific sort of impacts and also on how this medical technology—I'm sorry medical education technology—is going to impact education at the bedside and not just the classroom.
Erik: Yeah, and I believe we even talked a little bit about AI. Everybody loves that.
Karl: Oh yeah, the buzzword yeah everybody's got to talk about AI right.
Erik: We have to.
Brandon: So I have a question, so they're gonna talk a lot about possible changes to education that reflects technology and stuff like that. Are any of the things they're talking about things that we're actually gonna see happen here at Baylor, or are they more hypothetical?
Karl: I think mostly it's gonna be hypothetical stuff. We will discuss a few things that techniques that they themselves, or that other medical educators here at Baylor are using, right, kind of on their own. But as far as like talking about broad sweeping changes that are gonna be implemented we're not really going to get into that today. And some of the stuff we're gonna even talk about is gonna kind of like far out there into speculation territory, where it's not like it's just you know…there's the disclaimer these are our opinions, not the college's type of thing, right.
Brandon: So it's just stuff that it could happen maybe one day, or it's cool stuff that may happen or would be good ideas, but not official curriculum changes like that. No one needs to be thinking, oh wow the resonance podcast is so…
Erik: Cutting edge.
Brandon: Cutting edge…
Erik: I mean, we are cutting edge.
Karl: We are cutting edge.
Brandon: Well, who knows, maybe we are.
Erik: All right well, so on that note, to get us started with the interview portion to introduce the faculty that will be talking with. Dr. Anoop Agrawal got his BA from the University of Missouri at Kansas City, his MD from the University of Missouri in Kansas City, and came to Houston and did his internship and residency here at Baylor College of Medicine. And is now currently the Internal Medicine and Pediatrics Residency program director.
Karl: And our other guest does not need any introduction if you took our pharmacology class here at Baylor, but I'll introduce him anyways is Dr. Tyson Pillow. Dr. Pillow is a faculty at our emergency medicine department here at Baylor; he's an associate professor. He actually got his BA at Rice University and then also his MD right here at Baylor before doing a residency at the University of Chicago. And he is now working at Baylor like I said as a faculty, and also is the residency program director for our budding emergency medicine department and the medical director for our simulation and standardized patient program. We're very excited to talk to them both.
Karl: You guys mentioned in our talks before this for the podcast, the possibility of creating a paperless curriculum using materials like the iPad that sort of thing. What would that kind of look like? And how close do you think we already implementing that here at Baylor? What are some things you'd like to see?
Dr. Agrawal: Money?
Dr. Pillow: So, I'm gonna speak for Jared Howell, but I would highly suggest you all get him on the podcast. He has digitized his curriculum. He talks about how one of the first steps is to put the iPad in his faculties hands and get them used to that, get them comfortable with it. And then he also talks about how in transitioning from paper to iPad, specifically iPad but I should say tablet, but in this case iPad that the students…it becomes natural when you start to use it. It gives them the option of using paper if they choose but puts everything…and students take notes on the iPad—on the tablets—students manage their learning through the cloud servers, share through the cloud servers. That actually struck me teaching, helping to teach, pharmacology this year as well the number of students who wanted the slides before class, not because they want the answers but because they want to annotate directly on the slides. It has changed note-taking. And so the other thing I'll throw in is that per Jared, the actual cost is …it's cheaper to buy iPads for everyone than it is to print the thousands of thousands of pages of paper and I all the binders that he had. So he actually says there's a cost savings associated with moving digitally. I think people are uncomfortable with it. I like to…I wish I had done my research to come with the specific references, but you'll see this across the board. Well, I'm researching various things, but one of the very interesting things is, for example, when the stethoscope was first introduced. Apparently, there was a lot of backlash and pushback. Why wouldn't we just put our ear to their chest? What is this stethoscope thing? And then when PowerPoint came through, there's tons of articles when PowerPoint was first developed like, oh this is the devil. Why would we use this thing with these digital images? And what will happen to our 35-millimeter slides and our transparencies? And so you will get pushback and if anything that's probably a good indication you're headed the right direction.
Erik: Yeah, what was that, Kuhn's book about paradigm-shifting?
Dr. Pillow: Absolutely.
Erik: Well, that's a great point and actually kind of building off of a comment that Dr. Agrawal you made earlier. I was wondering, so there's an idea out there as you were alluding to that there's a possible to shift all the basic sciences education in an online format, like you know the likes of Khan Academy, wherein this model students would study independently to take USMLE before entering medical school, and then medical school would just be the clerkship. What are your thoughts on that?
Dr. Agrawal: And again I'm speaking out of turn, and so yeah these are my opinions alone, and they don't represent Baylor College of Medicine or my residency program, it's just …it's nice to have this discussion. Because yes. And there's actually…I hope I'm not breaking any new news here, but there is an active conversation going on at the NBME of making the USMLE pass/fail, step one at least. And you can see there's a slippery slope if that becomes past fail step two will probably become pass/fail. And I get why they 're—I'm sorry I'm going a little bit on tangent— you can kind of figure out the logic of why they're considering this. Because of the undue pressure that's placed on this one exam that could determine your whole career trajectory, and therefore students aren't actually paying attention to the material that's being presented every day in the classroom, or on the clinical setting. That's a whole podcast because I'm sure you can have a big conversation about that. But when you look at it in this context of, well yeah if you actually want to create competent, compassionate doctors. Just rebuild your medical school from the ground up with that as your goal, what did that look like? And if that requires mastery of some basic sciences and some knowledge, great. What is different about how you're delivering that knowledge at Baylor College of Medicine versus at Duke University versus at Vanderbilt versus at Harvard. It's the same material. It's not like there's some special codified material that's restricted to only Baylor College of Medicine students that they get this. So if you put the burden back on hey, pass step one, and you get into med school, and now we're gonna provide you the rich…now we have more time to give you the rich experience of the bedside skills…that the feedback evaluation skills, the real, you know, rubber meets the road skills of the challenges of everyday being a great physician and just put more, emphasis on that and give more time to develop those skills that you know. That's just an idea.
Dr. Pillow: Yeah, I also am speaking for myself, not for Baylor College Medicine. The…my disruptiveness is not as disruptive Dr. Agrawal. But you know I agree he's got some great ideas and they're great core principles. I think the method is blended and I think the method gets away from 8:00 to 5:00 Monday through Friday, and actually says how do we learn on the continuum. So I like to anchor a little bit more in competency-based. I like the ideas mentioning, so, for example, pass Step One and then do clerkship sort of things. I like ideas like that. When I look at it, and I'm drawing from again that I've had the privilege to work with dr. Reddy and the other faculty on pharm this year, I saw a range of learners. I saw—and this is actually in the literature I forget the actual author, but talks about stages of learning going from a dependent learner in stage one to independent learner in stage four—but you…we had learners who would ask application questions from the moment I got into the class and we had learners who struggled to get some of the basic concepts, and that's okay. But how do you create a model that supports all of them and really gets at that competency-based piece? Some people for mastery will take longer, but you can get to mastery level. Some people will get there faster, and how do we create infrastructure that supports that. And as I mentioned I agree, we do have—this is definitely a personal opinion—we do have this idea…this permeates almost everything, not just medical education that I must show you information on a slide to be able to hold you accountable for it. Then you get to an ER shift, and the patient doesn't care that you've read the book or not, and you're gonna end have to intervene. And whether or not you remember that slide is not nearly as important as being able to integrate what you've learned. Take your knowns, take your unknown to make the best decisions for that patients and save them. And so I really feel like again a blended model where you know maybe the length of medical school training doesn't have to change, but the…absolutely the way we do it has to change to create these competent, compassionate, excellent physicians.
Erik: On that note, I'm curious what your opinion is Dr. Pillow, especially as somebody who has taught the first years pharmacology course, or help teach, what are your opinions on streaming?
Dr. Pillow: The…so you're asking streaming from the standpoint of?
Erik: You know, that translates into less people in the classroom when you give your lecture.
Dr. Pillow: So I actually reject that theory. I actually think that these are slightly separate issues. The number of people in the classroom is dependent on what content, what applications, what activities you have in the classroom.
Erik: If you don't record it.
Dr. Pillow: If you don't record it, or if you do record it and make them responsible for application, right. So we actually did some of that in pharmacology this year. We definitely had the didactics, but then you come in for a case review, and you applied it. And we actually were very happy; we had great attendance at all of our optional case reviews. Now partially because yes, we did not record them, but none of the material was new, we provided answers, and people still came because they want to know how to apply the material and actually use it in meaningful ways. I think the challenge of streaming is not if we stream we will lose people. The challenge of streaming is if we stream how do we continue to make the medical school meaningful. How do we continue to make the time, face to face time, meaningful? How do we move to a more competency-based, because honestly at the end of the day if I create a competency benchmark—you want to stream, you want to read, someone else just comes to the class to do active learning, and some we all hit my benchmark— I'm okay.
Dr. Agrawal: Sounds like different learning styles.
Dr. Pillow: That's true, the VARK, he's a VARKer.
Dr. Agrawal: I like what you said, are you an individual learner where you want to sit in your little…in your bedroom and watch that, or do you want to have a social experience, and that's how you engage.
Dr. Pillow: I think it's both, right it's blended, it's both.
Dr. Agrawal: I agree.
Dr. Pillow: And if you, if you…so I don't think of streaming or class time. I think of how do we leverage streaming in a way that augments class time. And we got to get away from these ideas that if we don't teach it to you directly on the slide, then we can't hold you responsible. I'm gonna teach you—I think I even said this during pharm—I'm gonna teach you A, I'm going to teach you B, and I'm gonna test you to see if you can figure out A plus B equals C. And I'm gonna give you some examples, A plus D equals E, B plus C equals P, whatever. And then you come in, and you figure out, okay I can apply this now. That is where I think…so I'm actually Pro streaming, and I challenge the educators, myself included, to do better to keep pulling students to…face-to-face time, and make it meaningful.
Karl: So a lot of our discussion is kind of bounced back and forth around different settings for this education but focus a little bit more on the traditional classroom or larger group setting, and we're just curious like if you have some real clear specific—I think we talked a bit about like Google glass and stuff—but specific education technology innovations in mind for bedside education experience.
Dr. Agrawal: So that's where I do most of my teaching there. Unlike Dr. Pillow, who does predominately mostly classroom with some clinical. Mine is pretty much majority clinical, and that's where currently, the current tool, my preference…preferred tool is the iPad or the tablet. And what it is, is, do you think about…where unlike the classroom, what I pitch is that as an academic educator, clinician educator, my classroom is a mobile classroom. So I am on the go where…the team is on the go; we're going from patient room to patient room, we're spending time in hallways, we're spending time in our team room. We can be anywhere in the…in the building, and what kind of device or what kind of tool is there that you can have as a mobile tool. I mean no one wants to be carrying their laptop around, you know it's the bulky mobile factor, sure it's mobile, but it's not exactly designed to do that type of thing. Sure you have the Wow's, the computers on wheels, or workstations on wheels, but again that's not…that's more for the care of the patient, there's not going to be ability to do other educational type things. So again for me what I've found currently is something like in the iPad, which is…which is that ultimate tool of having access to all types of applications. And there's the specific—we've talked a lot about white board type ones—but then there's very specific medically oriented applications. Another one I'll throw out there and mention that's great is called Draw MD. It's free and available I think on different platforms, and it's a…it's designed…the creator's have designed it as a patient education tool, but for me, patient education is just the other side of the coin of medical education. They're the same …they're you know different sides of the same coin. And it has fantastic templates and pictures, and again this goes back to getting the visual learning of the learning style. You know if I'm trying to explain to somebody how their thyroid works, are they gonna get it if I'm just talking out loud and, err well you know your pituitary is you can create this hormone called TRH and your thyroid was gonna…you know versus if I draw it out. I think there's something to be said there that it doesn't matter what type of learner, you're gonna prefer a learning style that's gonna be visual. And so it's crazy that I think that there's so many complicated concepts or just physiology that we teach at the bedside to the patients, as well as to our students and residents, that gosh, we wish we could just draw or have cartoons of things, and that's what the device lets me do. And it lets me have what are called, you know inside the actor studio here tips, if you have a fantastic medical educator it's because they've done it a few times. It ain't their first rodeo; they have a teaching script. They have refined and finessed how they teach this concept, and it's been, you know battle-tested with hundreds of other learners and students. And so, the technology allows for efficiency, allows you to have that same content but now in a much more robust style that you don't have to redraw that picture every time. You have…you have that picture already there, so your starting point is a little further down the road.
Karl: That makes a lot of sense.
Dr. Pillow: For the bedside, I agree. I love whiteboard apps, so that's what I have; that's what I go to for both patients and learners. I think the other part too is I go off script a little bit and actually don't care about the tool. I try to teach curation of the apps that are available, the materials, even just the idea of, yes you have up to date, how do you use it real-time? Right, how are you…how are you going to take this and actually make decisions with patients? And it gets into this idea of information management. The information deluge, and how we actually look at this and say, alright this is how we practice to stay up to date to challenge our assumptions even when you did something one way yesterday, is there anything new today, or next week, or next month, and how you actually pull that in. And so again, the tech, computers have been around for a while. So the tech is not necessarily new at all, but the way we use it, we actually have to train ourselves, train our learners, and even train our patience, right. They can't…I would rather they not Google three symptoms and then come in with XYZ, and so how do you…how do you actually help your patients to navigate in a meaningful way? Curating information, knowing which sites to refer them to, teaching them how to use them in a more meaningful way. So that's what I try to do bedside.
Erik: Well, how do you see advances in technology impacting educational opportunities and specific sub-specialties and specialties?
Dr. Agrawal: Well I think I alluded to one concept earlier, which I feel like we are…that we currently have a deficiency, and I would say, or we could do better in medical education, which is direct…more direct observation. Because really that at the end of the day is the best way to validate and verify that this individual has the competencies and ability to perform as a physician. But it takes a lot of time and effort for faculty to always be in the room, and I think if something like Google glass 2.0 or what-have-you can get…the usability index can again become lower, so it's low-hanging fruit, anybody can pick it up and do it where you can just stream it. Stream it live. I can be sitting in the conference room in the same facility, and you don't feel like I'm necessarily right there in the room when …it's different when I'm in the room watching over your shoulder, you notice my presence. But sure, you know I'm watching you on the glass, but you probably subconsciously, after a minute or two you're just…you've forgotten me, you're wearing them, and you're just doing the care. And I can now provide you some real honest feedback of how that visit went.
Erik: Right, put it on the medical student?
Dr. Agrawal: Yeah, exactly. It's like a GoPro let's just… look, hey, it's happening in other areas look at the police force, right. You got the body cameras, same thing. I just mean body cameras for med students and residents so we can kind of see what are they actually seeing, what did the patient actually say, what implicit biases are they not recognizing in their own care delivery. And I think that's where I see the next big leap, and I think what's been the barriers again, having something that's cost-effective, easy to use, integrates with our systems that can make it happen. I think like…I feel like we're just one…very close.
Erik: It sounds like do you see that specifically…I mean obviously, for your end, family medicine affecting that, but do you see that across the board? It might not be…that might like, for surgery, for instance. Like would you see something like that?
Dr. Agrawal: I don't know, we could see what Dr. Pillow thinks.
Dr. Pillow: Oh I definitely think…I think any skill set where one must demonstrate procedurally, especially. If I can actually record you performing the procedure, even to the point of…there's actually some literature, very interesting literature and forgive me because I don't know all the references, that are suggesting that educators no matter their gender are actually rating female trainees lower on milestones than males. And there's actually several articles out now about that. So, we're trying to look at that and figure that out. Is that a matter of faculty bias? Are there factors of the learners themselves? We're not sure. We're looking at that. Wouldn't it be amazing if we could judge someone's procedural skills not based on whether we knew it was a man or woman or…but actually look to see, watch their skills and look at their outcome? So things like that, and breaking bad news. I've …we've absolutely, every attending everywhere ever has had the experience of your resident tells you X and you walk in the room, and the patient tells you the inverse of X. That is just something that happens, and I then I've had it happen to me myself. I'll go in a room, one time the patient will tell me yes to a question, the other time they'll tell me no, and how do you resolve that? How do you reconcile that? Well actually having that input you can actually say, oh here's where you've led the patient to answer that question, here's where they were actually going, here's where they were uncomfortable. So lots of opportunities there and I think to…the other area I think is something that already exists but we don't use a lot is just video education. So if we're gonna consent patients for procedures wouldn't it be nice if they knew what we're gonna do, right? Now if you want to go put together a car engine and you had no idea where to start what would you do?
Dr. Agrawal: YouTube.
Dr. Pillow: YouTube, you look it up. Alright, so sir we're gonna take out your appendix. Sign here, I've explained that to you, you should go. Alright versus sir, so we're gonna take out your appendix, okay here's an instructional video about that, and here's what we're actually gonna do, here's how we're gonna make you comfortable, here's why we're doing it, here's the alternatives ready for them to go, right. So I think there's medical education at direct observation, I agree with dr. Agrawal 100% that when we figure out how to do it easily, manage the issues of HIPAA, FERPA, everything else, then that's gonna revolutionize the way we do education. It's gonna take a lot, but it will revolutionize. But then also on the standpoint of other aspects, there are lots of applications.
Dr. Agrawal: I'll mention a couple that, Dr. Pillow I'm surprised you haven't brought up. Simulation, and of course the other rising tide is pocus or point-of-care ultrasound. I think those are all there to advance this technology that are gonna continue to grow and have a significant impact in educational opportunities.
Dr. Pillow: Wearable technologies as well. We will…we will be walking around at some point, we'll be walking around with the tech—whether we're part of the board or not I'm not sure yet—we'll be walking around with tech that we'll be able to report heart rate, blood pressure, it'll be able to sample things through our skin to decide when we're stressed, when we're not stressed. At some point it'll take small little blood samples or— just throwing out ideas here, that'll give us an indication of where patients are with X-Y-Z. And then from that standpoint, patient education on use, provider education with how you manage patients in an outpatient setting with wearable technology versus having to bring everyone in at regular intervals. Those sorts of things. All sorts of different applications.
Erik: Well, and how about AI, I mean that's the hot-button topic now. Obviously, people talk about it mostly pertaining to radiology but do you see that affecting even just medical education in any way? Or…
Dr. Pillow: The interface I think, because you will have to learn—there are probably things I'm not thinking of right now obviously, or we're not thinking of—but the interface, just knowing how to use AI in a way that is useful and meaningful and continues to add value. So if you have…we see this some with our electronic medical records. So when do you accept the recommendation of the electronic medical record? When do you actually reject it? Most people now anecdotally will tell you, see that click cancel, click cancel, just click through it. Well actually it's based on data, and it may have some applications. The same time you have to know when the patient that's not flagging for CAD risk factors and ACS shouldn't go home. I still need to bring them in. So I think we're gonna have to teach, learn ourselves, and then also teach how to use these technologies that are going to be so important for patient care.
Dr. Agrawal: Yeah, I think it reminds me of the book by Daniel Kahneman, that Thinking Fast and Slow. It's almost like AI is type 1 thinking, it can recognize the patterns and come to the diagnosis, and it'll be right 80% of the time. Versus…Pillow is giving me the up arrow. Higher.
Dr. Pillow: More like 92%.
Dr. Agrawal: But then what's our role gonna be? Ours is gonna be to think slow and catch the other, say 15-20% where AI's got it wrong in terms of what it could do. And so I think there's...yeah a lot…I think with us as a profession, this is speaking more broadly, we should be kind of thinking ahead of this because this is a potential disrupter to our own profession, in terms of what is going to be the role of a physician. Because I can see a day where if I have a sore throat I don't need to go see the doctor I go to CVS, pick up a kit, swap my own throat, put it in the thing, gives me a positive or negative like it does with a urine pregnancy test. I enter my weight, my age, it kicks…ask me allergies…it kicks out a prescription…
Erik: Vancomycin, right away. I'm just kidding…
Dr. Agrawal: It's right over there at the CVS counter, I go pick it up, and there's my amoxicillin waiting for me. I don't need me. You don't need an MD. So I think I see roles for AI, and then again, how does that …what's the role the physician in that new world. I think it's for the higher-order thinking, for the complexity that we are get excited about. That's what you know, as students and residents, you know that's what gets us up in the morning is when we see those cases that are really challenging and make us think that makes it more rewarding. So I think it would help us by doing more rewarding and meaningful work day-to-day, but I think yeah there can be a risk where we can erase ourselves from the equation of that…what is health care if we're not careful.
Dr. Pillow: That's a good push for emergency medicine; people will still shoot and stab each other.
Dr. Agrawal: I don't know those Da Vinci robots may be able to repair you on their own.
Karl: Yeah, I think it's been very fun talking to you guys. Thank you very much, Dr. Pillow, Dr. Agrawal.
Dr. Pillow: Yeah, it's been great.
Dr. Agrawal: Thanks for having us; this was a lot of fun.
Karl: I'm seeing a common trend here, with all these innovations it's really important, but that decision-making process at the heart of it is something that us doctors very much will still be needing to do moving forward.
Dr. Pillow: Thank you all for having us.
Dr. Agrawal: Thanks, guys.
Brandon: All right, that is it for now, we would like to thank everyone who took the time to listen to this episode of the podcast. Special thanks to Karl for writing the episode. Thank you to our faculty advisor Dr. Poythress for helping us put everything together. Thank you to the Baylor communications department for help with the production and website and thank you again to Drs. Pillow and Agrawal for taking the time to be interviewed by us. We hope everyone enjoyed it and hope you tune in again soon. Goodbye for now.