Panel discussion and Q&A session II

Panel discussion and Q&A session II

Reinold Gans: Talking about Grand Rounds, I guess we all encounter the same problems everywhere regarding attendance and so on. And one of the things, I think, is that trainees these days much more like snippets, small pieces of learning. So don’t we have to go more into microlearning just on the spot—it could be during morning report—and give them just small bits of information that is relevant for what they’re going to do the next hour? Because that’s what really entices, I would say, trainees. But I would like your comments.

Wieslaw Oczkowski: Yes. Yes, absolutely. But it also depends on what your objectives for Grand Rounds are, to start with. If you educate residents or students, that may be the right approach, absolutely. Anybody in the educational field knows that >20 minutes of a lecture and the participants are done, they don’t hear anything more after that. So you have to sort of remember that itself. But then, you know, for me, Grand Rounds are very important to bring my faculty together as a collegial type of event and to have coffee, hallway discussions, and so forth. It was also very important that every faculty member, residents, and students could learn what other people did, you know, sometimes you just wonder, what did they do here, like what kind of research are they doing or what clinical work are they doing? What’s their latest clinical work?

So it’s many, many, many goals for Grand Rounds. It really depends on what your goals are. But I agree, a 60-minute lecture… and one of the most common things—and I’m also to blame many times—is running right to the 60-minute clock with a lecture. Everybody’s already agitated. Half the people are already leaving and there’s no time for interaction. There’s no time for questions. That’s absolutely the wrong thing.

Roman Jaeschke: I will comment on what you asked. You know, I presented here the vocabulary of, call it, basic evidence-based medicine (EBM). But my goal would be that after the end of a 2-week rotation, the residents will understand those things. We had something—I’m not sure if you’ve seen that—something called the ACP Journal Club, which was summaries of relevant, newly published stuff. The biggest problem was to find 20 papers every 2 months to fill it. So you had 2000 papers, you screened it, you had 20, and you’re trying to summarize them.

What we noted is that people were not able to read it with understanding. So my goal for the month was to use exactly the snippets that you are talking about to talk about this particular detail here, and this particular detail there, and usually in reaction to what they said. So they used some word or phrase and I was like, “Who understands this word?” and it turns out usually almost nobody. And then you could talk for 3 or 4 minutes about that particular word. But, that’s true, you know, in my lifetime, we went from 60 minutes to 30 minutes, to 20 minutes, to 15 minutes. We went down to 6 minutes this morning on case reports. The attention deficit disorder is flourishing and the attention span is clearly shortening. And we have to acknowledge that. We have to acknowledge what the other people are.

Michał Nowakowski: I actually think it’s physiology that we have to acknowledge because…

Roman Jaeschke: That’s resilience.

Michał Nowakowski: Well, you mean they are just less stubborn to pretend they are listening. The attention span that the human race does have is ~4.5 minutes. This is how long you can concentrate if you concentrate fully. This is what physiology tells us. Of course, very randomly do we need that sort of concentration because this is the level of concentration when you sweat from the effort. But anything longer than 15 is probably not possible. And then it’s our choice, for example, as lecturers, to use the attention gaps in a planned way so that we plan when people can relax and then bring the attention back. Yeah, especially when I’m speaking.

One thing to add… Thank you, Grzegorz. One thing to add is that I was very hesitant when you asked if we have Grand Rounds in our hospital because Grand Rounds are a typical North American concept, we don’t really have them, at least in Poland. But 3 years to go, we introduced in a hospital something like a teaching program, a series of lectures and stuff.

What we have noticed is that there are very few people attending them, but we recorded all of them and we created the repository. And the repository is extremely popular because this is the sign of today’s time. People want to digest the content when they have time and possibility or when it bothers them the most, because tomorrow they have a case to do. So, they will review the—whatever—the prophylaxis of pulmonary embolism for the case. Okay. So that might be another flavor to add. Please.

Reinold Gans: The other thing is, we were talking about aging and I was thinking, what is it, last year I did online Harvard Medical Education, what was it, 40 hours or more, 5 days. And it was 12 hours in a row. I did it in the afternoon, in the evening, because of time difference, and I loved it. And still, I had a pretty good attention span and I was wondering why that was. And the thing is that I am building upon experience. I hear a talk and I pick out maybe 1 or 2 items that are new for me.

So I just add a little bit of knowledge, but it’s completely the other way round if you are an inexperienced student. Then, after two sentences you have heard maybe several new things already and then you are supersaturated within 5 minutes. And then what you end up with is that you lose the speaker and thereby lose the attention. So, it’s always very important that you have your audience in mind. And it’s true, if you do not interact, probably it will not hit the hippocampus, it goes one ear in and the other ear out.

Michał Nowakowski: Well, hopefully it goes at least in, as there are some chances for subconscious learning, too.

Roman Jaeschke: It applies to all situations. My own is, we’ve done an experiment. Usually, when we round in the intensive care unit (ICU), we have the whole entourage, 10 people. When we asked them, in the middle of the round, how many paid attention to what was being said, it was less than half, and more than half of those who were not listening refused to say what they were thinking about.

Michał Nowakowski: Well, we’ve learned, probably food. Okay. But something really interesting in the presentation of yours was that you were so focused on the evidence, yet the reasons why people do not follow up on evidence, do not use them, are those typical cognitive biases. Our inability to properly relate to probabilities, to digest big numbers, to be biased by the way things are presented, and so on. Do you think it should be merged together, like learning about EBM and about cognitive biases? Like at the same time? Because I have the feeling that we preach about those things, but separately. But one without the other is meaningless.

Roman Jaeschke: And everything that I presented here would be to be taught… This is the clinical reasoning session. You cannot truly reason if you don’t understand the rationale behind it. So it’s clearly incorporated. There is no... And you know, if you want simply to follow cookbook medicine, you don’t need to know any of this except that your cookbook keeps changing on you all the time. You know, we were debating whether to do this mammography at 50 or 60, and now suddenly we are at 40. I’m not aware of this evidence change.

Michał Nowakowski: I strongly encourage the audience... Oh, wonderful, Grzesiek… The microphone is coming. Please wait a second because for the sake of the recording and people online, we need everyone on the mic. Thank you.

Audience 1: I have some general questions as an internist. What do you think is the ideal match between methodology theory and the practice in training our future residents? And what do we do with so many different educational systems—I’ll make it simple—across Europe? Because if we had the best system, educational system, we would have the best doctors only on that side, which is not the case because the young generation, they have enormous mobility across Europe and they look like they are performing equally well in different contexts. And I can tell you my experience. During the pandemic era, we were training very young people who became part of staff and they were extremely resilient and effective. So, what is your idea behind this?

Roman Jaeschke: You mean very receptive or resilient?

Audience 1: Resilient.

Roman Jaeschke: Resilient to difficulties of the situation or resilient to learning?

Audience 1: No, resilient to difficulties of the situation. Even better than the seniors.

Roman Jaeschke: The short question is, I don’t believe we have an answer because we have no way to measure it. On the other hand, when we started the EBM movement 30 years ago, we wanted to make a methodology specialist out of everybody. And it became very clear that 95% of people are totally disinterested in it for a variety of reasons, including cognitive limitations or pressure of learning other things, and so forth. And I would still insist that people who tell others what to do, authors of practice guidelines, should have those skills. If they don’t have those skills, they are powerless to produce... they are harmful—as much as this.

So, really, how to integrate it? We integrated the workshop on how to read medical literature and how to write research grants in today’s meeting here in the morning. And the person who was running it came enthusiastically to us saying, you know, I had residents from Katowice (?)—So was it? Is there anyone sitting here?—saying, we learned here almost as much in one and a half hour as we learned over months in the sessions that were somehow run differently. So, as there are different ways of teaching the introduction of central lines, there are probably different ways of teaching the evidence concepts, and those who will down the road tell people what to do should know them. So, it’s not the same for everybody.

Michał Nowakowski: And my answer would be that, I think, the time when we had the one-system-does-it-all are thanks God over, and they will never ever come back again, and no one will come back with the best solution for everyone. Why? Because if you think what’s the best system to educate people, then I will immediately ask, for what? Are we sure that it’s the same education that is needed to become a good family care physician and a neurotrauma surgeon in a university hospital?

Well, if not that, then maybe we can accept that since every physician deals with different patients, there is some diversity needed. We need to work on best methodologies, we need to share the experiences, but the best method to teach medicine, I think it doesn’t exist. At least I would be very hesitant to even pursue that track. Medicine became too complicated. It’s too large. In every other field of human development, like IT, culture, everything, people go towards the specialization. You no more go to a music school. You practice a particular instrument. You don’t go to acting. You have different school for films and for movies or for theater. You don’t study informatics like it was 20 years ago. You become a media specialist or a programmer. Why should we have a general physician with one good solution for all?

Wiesław Oczkowski: I’m not sure about that because patients don’t present with an acute myocardial infarction (MI) or a stroke, obviously. They present with other nonspecific things where you need to have somebody who can look at it—sort of stand back and potentially direct the care or start the initial evaluation.

Roman Jaeschke: Artificial intelligence.

Wiesław Oczkowski: Oh, maybe, maybe. Actually I would love to have artificial intelligence on my iPhone to work with me. And one of the things that every physician, I’ve sort of said, agrees to, is that I wish I worked with a buddy always, like another staff consultant physician [with whom we] shared a patient population and we worked with the same patients—one time it’s me, sometimes it’s my partner—and you get a different perspective, a different feeling, as opposed to our traditional training, which is still ongoing sub-sub-specialization and alone.

You have your patient, you have you, and you’re responsible for making all decisions with this patient. And sometimes it’s so refreshing when my patient ends up in somebody else’s hands and they say, how long is it that they’ve had disorder X undergoing? They have disorder of X? You didn’t see it. So, I think, one thing is that we need to start thinking about maybe teamwork and working in teams for our patients’ benefits.

Michał Nowakowski: Absolutely agree. Well, I’m a surgeon. We work in teams. So for us, it’s kind of natural and we are quite surprised that not everyone...

Roman Jaeschke: And the second surgeon says, “What did you cut out?"

Michał Nowakowski: Yeah, that’s what the colleagues do, always, you know. Questions from the audience?

Audience 2: Yeah, thank you very much. I have one [piece of] outside information. I’m not a physician. I am an IT person, but I have heard all the speeches, and this conversation in particular is very interesting. I would refer to what we teach to medical professionals. I was thinking if we shouldn’t teach medical professionals a certain way of thinking, a certain set of skills, so that they can adapt to solving different problems.

I really liked very much what Mike was saying about courage. It’s really very transparent to me. Like I would prefer to have a surgeon operating on me having courage to solve the problem, I wouldn’t like this person to have shaky hands. Maybe one skill is courage, making decisions, not being afraid to make a decision. And actually, this is something I would like to point out.

Maybe there are other skills in medicine like learning – the ability to learn, ability to understand the risks that we were talking about, like I’m trying to cure you, I’m trying to give you the treatment, but we need to understand that there is risk related to the medicine and the procedures that I am going to apply and I want to understand the risk related to the procedure. This is, I think, the general set of skills, which are very important and maybe there are different areas, but all areas would benefit from those skills.

Michał Nowakowski: I fully agree that there are some general competencies which everyone should have. I think it probably didn’t transpire from my previous comment that there are some things which are common, like decision making or understanding, communication skills. A lot of stuff is common, and they should be taught. I’m not quite sure whether we know the best methodology or whether we should have one. If we have a variety, then probably we will be moving the field forward some way. It’s like evolution.

Wiesław Oczkowski: One of the most difficult things to teach, if at all possible, is actually behavioral skills and professionalism. All of us who are actually in the profession know colleagues who are “great physicians,” but they’re always, you know, like this, just that’s the way they are. And we have the same thing with residents... They seem to know everything, but, boy, I’m not comfortable that they’re ready for practice, and you sort of decide why and it’s really related to their approach to patients, other colleagues, allied health professional, nurses, how they may be late often for events or rounds, or a little too sick too often. It’s like all this stuff that’s not an EPA necessarily, very difficult to assess, very difficult, if at all possible, to train and teach – the behavioral aspects of sort of human nature and professionalism.

Reinold Gans: Yeah, I fully agree with you. I was thinking about the feedback. And what is very helpful for me is if I’ve got that gut feeling, I’m looking at the milestones for professionalism, for communication, collaboration, and most likely those milestones will give me the words to give the person feedback why we are not comfortable with this entrustment decision.

Michał Nowakowski: Absolutely. That was a fantastic comment, thank you very much. I’m looking at the audience for questions. There are no questions online, so I think it’s safe to conclude this session on time. There is a question? I’m sorry, I missed that one. Okay.

Audience 3: Hello. I have a question that this gentleman right here mentioned. You said during the pandemic you had younger staff that joined. How young, if I may ask?

Audience 1: [Duration of training varied from 3 to 5 years.] They were enrolled in the staff.

Słuchacz 3: Okay. Because it was mentioned, it would be nice to have somebody with you, work in teams, a buddy with you. In the spirit of continuing medical education, how far are we from implementing or is it in play already – apprenticeships or people not in medical schools yet. Is it a good idea to start training younger generations of people as medicine becomes more complex? As it was mentioned, it’s too large, you start to specialize more. Is it a good idea? Is it being considered to start training people at younger ages?

Wiesław Oczkowski: I think medicine has always been an apprenticeship. It really has... You joined a colleague who’s already trained, and you work with them, so it’s always been like that. Fortunately, I believe there actually is much more emphasis on teamwork, working not only with your colleagues but also with allied health professionals, the nurses, making sure that you know what they’re doing, how they work with you. That’s crucial, but we haven’t taken that step once you graduate. Except surgeons, you guys are lucky I guess, you do have a secondary surgeon in the operating room (OR) often that works with you, but on the medical side, we don’t have 2 intensivists. You may have an intensivist and a more junior physician with you.

Roman Jaeschke: You feel lonely.

Wiesław Oczkowski: You feel lonely, and you feel sometimes overwhelmed about the decisions you have to make on your own, where it would be nice to actually have lunch with a colleague and say: “You know what? I’ve got this patient in room 5...” We used to do that.

Roman Jaeschke: But it may increase your anxiety. [unrecognizable]

Michał Nowakowski: Okay, thank you very much for all your comments, for participation and questions. I would like to thank the speakers for the very nice presentations. I did enjoy this session a lot. Hopefully you also did. Well, I would like to welcome you to the next Medical Education Forum next year because this one unfortunately is over. Thanks a lot, have a nice time in Kraków. Well, good job, everyone. Thank you.