Is deep learning in medical education possible?

Despite recent buzz about shifting resident education to community health centers, hospital based education is here to stay. The model of education, though outmoded, is simple. Get residents exposed to as much disease as possible, in the shortest amount of time. The future of American health care is not in acute management of tertiary care; but in integrated, team-based care. To get there involves focusing not only on educational content, but also on the process of how we teach and learn.

Consider a typical inpatient medicine service, with ten members to a team: an attending, senior resident, three interns, three medical students, a pharmacist and a pharmacy student.

First, some numbers:

Combined years of training: 50
Hours spent on clinical rounds (weekly): 30
Hours devoted to education (weekly): 5
Hours devoted to team building, quality improvement, and longitudinal care: 0

The numbers speak for themselves. Clearly, as a system, we have chosen to devalue team-based education in favor of teaching isolated knowledge to different training levels. This is the issue of content. But what about the process of rounding? Two simple concepts would go a long way.

1. Teach clinicians cognitive skills. This idea comes from the Right Question Institute, an organization dedicated to teaching students to ask critical questions. The cognitive skills involve three types of thinking:

Convergent thinking.  This involves integrating a host of information for a single purpose. For instance, looking at a list of medication and deciding which contributes to delirium. 

Divergent thinking. This looks at the process from the opposing spectrum: given that a patient has confusion, what medications could be causing this? 

Metacognition.  This is the process by which we “think about thinking” — evaluating, judging, and gauging our strategies to approach clinical thinking. This could involve asking: we approached the diagnosis of heart failure physiologically; how else could we have approached it?”

Hospital-based models of care involves all three capacities, though highly skews towards convergent thinking. The divergent process of generating differential diagnoses is quickly losing importance as technological tests proliferate. If you can read the CT scan of a patient with abdominal pain prior to seeing them in the flesh, you need not think divergently. The highest yield change may be to teach tools of metacognition, as these lead to new approaches to patient care, and sparks curiosity.

2. Create opportunities for deep learning. One model of education describes learners as superficial, strategic and deep. The superficial learner does purely what is needed to get by — in the case of the hospital intern, maximizing the efficiency of computerized orders. The strategic learner focuses on what he needs to get ahead; presenting information clearly and looking up facts about a case. The deep learner, in contrast, often asks bigger “why” questions about approach to medication management, physiology, or the social lives of patients. Incentivizing deep learning involves permitting time for intensive reading, encouraging development of multiple cognitive skills, and mobilizing knowledge from each team member.

As healthcare transitions to a team-based model of care, medical education must follow. Creating conditions for deep learning may be this leverage point, if we dare to think differently.

Tom Peteet is an internal medicine resident.

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  • Shirie Leng, MD

    Tom – A little frustrated are you? I totally agree. The residency education system is old and not applicable to today’s medical environment. Some thoughts:
    As an intern, your survival often depends on your facility at superficial learning. I remember learning to write “preventive” orders for everything I could think of so the nurses wouldn’t call me. If you want to learn deep you’re drowning.
    We have to remember that every resident was once a med student and every med student was once a star undergrad and every star undergrad was an overachiever in high school. Doctors excel at strategic learning. Deep learning requires time and a genuine interest in the subject matter that many residents have already lost.
    I think a large part of the problem is the use of residents as grunt labor for the higher-ups. While there has to be an hierarchy, the intern gets left writing computer summaries in the office while the care of patients goes to the seniors, or, more often, to the nurses. If we want deep learning, we have to get our residents involved in direct patient care as much as possible. Right now the opposite happens.

  • buzzkillerjsmith

    I don’t know about deep learning in medical education, but deep hurting has been a constant for decades.

    • Dr. Drake Ramoray

      The difference is the deep hurting is no longer limited to the education component. Why cultivate critical thinking when you’re gonna be beholden to algorithms and treatment goals mandated by managerial types? Much like a previous article that interns spend too much time in front if the computer not taking care of patients, why cultivate critical thinking in medical school to train disruptive physicians.

      Sounds like med students and residents are getting just the kind of training they need to be 9-5, meaningful use meeting, algorithm following, mandated goal meeting “providers” that are “leaders” desire. This doesn’t even take into account that I thought learning how to think critically and learning how to learn was something for high school and maybe college. If you are incapable of critical thinking on your own by 22 certainly 26 as a resident, I don’t think it’s your program’s fault. Wait till fellowship (unless he is foolish enough to go into primary care (talk about lacking critical thinking)) for this young upstart when there is virtually no formal teaching at all.

  • pedsmeded

    It may be cheaper to hire residents, but we need to take this discussion seriously if we are to train residents as optimally as we need to in order to meet the needs of society. The public has noted that it would like 2 things from its physicians as it relates to this discussion: 1) well-rested residents who have limited access to patients and poor continuity of learning, and 2) well-trained attendings who have seen it all and will ensure the they receive the highest level of care. While both of these are great things to hope for, they are in a delicate balance with one another, and one that is challenging for those outside medicine to fully appreciate. Dr. Peteet’s argument that we need to capitalize on the deepest learning possible with the time that residents are at work seems spot on in this regard. This seems like the best way to ensure we produce physicians who are ready to deliver on the expectations of attending physicians after they have completed training.