What would a flipped checkup look like?

When we moved to Irving, TX and I decided to join a practice in nearby Lewisville, I realized I wanted to know more about the schools in the area and get a feel for the culture of the teachers that would be teaching my patients and kids.  I searched online and found great and encouraging information about Carrollton-Farmers Branch, Irving and Lewisville school districts.  I also looked up several teachers and administrators.

While I expected to get good information, I never expected to learn a concept that I hope to incorporate into my medical practice, but that is exactly what happened.  I followed an educator on Twitter who is the technology integration specialist for the Lewisville Independent School District and she has since “introduced” me to a concept known as the flipped classroom (even though she doesn’t know it yet).

Wikipedia describes flipped learning as “a form of blended learning in which students learn new content online by watching video lectures, usually at home, and what used to be homework (assigned problems) is now done in class with teachers offering more personalized guidance and interaction with students, instead of lecturing.”

So, students watch lectures at home in the afternoon then come to school the next day to do homework and other projects during class time.  This gives the teacher time and opportunity to address what the student doesn’t understand from the lectures rather than have students turn to their parents for their calculus homework (when dad had trouble passing algebra).

So, how does this apply to me and my practice?

I’d like to have more patients to do “flipped checkups.”

In the flipped classroom, student listen to lectures at home and come prepared to do work and application related to the material.  In a flipped checkup, parents would read and learn about the upcoming checkup (check out this page on my blog: checkups for an example), develop specific questions and then allow me to get into deeper, higher-level education when they come in for their checkup.

Yes, contrary to the stereotype, you did just hear a doctor advocate that his patients do online research prior to their visit (but I want it to be good information).  In fact, it’s the reason I started my blog in the first place.  I wanted my patients to be able to access my advice (in effect, access me) when I wasn’t there beside them to answer their questions.  I wanted them to have a place to go that had accurate recommendations that fit with my philosophy. (So, why not have them actually be my recommendations, right?)

Here’s an example of how it could go:

Family has 4 months checkup scheduled.

They review the 4-month checkup blog post.

Family comes in for a 4-month checkup.

They say, “We read your blog 4-month check-up blog post and are ready to start solids and he seems to be developmentally OK but we did have some more questions about helping him sleep through the night.”

This allows me to touch on the other areas for clarity and completeness but spend the majority of the rest of the visit discussing in depth about sleeping and some options for sleep training (or not, depending on the family’s preference).

When the child is older we could cover the topics located in my Masters in Parenting series to cover some topics of development more deeply.

So, this leads me to some questions for you:

  1. Is this something you’d be interested in?
  2. If you wanted to do it, how could I make it easier for you?

Justin Smith is a pediatrician who blogs at DoctorJSmith.  He can be reached on Twitter @TheDocSmitty.

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  • azmd

    Actually, I would just prefer that my child’s pediatrician have enough time to devote to the visit so that whatever questions I have can be answered in a thoughtful manner. Having an online study session prior to the visit makes me feel like the main goal is to offload the education component of the visit onto me and my free time. Parents who are interested in reading about early childhood development are already doing that, just not in a regimented way that allows the doctor to check off various boxes about what education has been provided by his practice.

    Come to think of it, it’s kind of like Maintenance of Certification that way.

  • JR

    I can imagine some comments hers being disturbed you think you should be talking about anything that isn’t a “disease”. A doctor’s job is to treat disease. The rest of that stuff is outside a doctor’s realm in the opinion of some.

    I personally like the idea for a few reasons. You’re preparing the parents who know what to expect for the visit so they can prepare their kids. It also gives perspective parents a chance to get to know you and know how you practice, which means you’ll attract parents who like the way you practice. That will lead to more satisfied patients and parents, leading to a more satisfied doctor… hmm, win-win.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Let’s start with the teachers. Teaching is not about lecturing to a group of semi-awake kids. It’s about inspiring thirst for learning. Videos can’t really do that. Teachers should teach, and kids should go home and apply what they were taught, preferably on their own, and when they get to calculus, few if any will accept help from a parent anyway. I am not opposed to having TAs hold sessions to help with homework, but teachers should teach (in the full sense of the word), and if they are incapable of doing that, then perhaps they should do something else.
    To make sure I am not going against the younger generation’s preferences, I held a little impromptu referendum in my living room just now, and the unanimous opinion was that “I don’t want to watch stupid videos on the sh**ty computer” (my apologies for the language, we observe the first amendment in my house :-)

    Same goes for doctors and their teachings. Agree with azmd 100%.
    And let’s not forget the people who will be left even more behind than they already are by this flipping thing.

    • HJ

      How do you know videos can’t be part inspiring?

      Wouldn’t it be better to wait for the research instead of bashing a flipped classroom?

      A few years ago I took a distance learning class at my local community college. I watched taped lectures. I was able to review difficult concepts.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        We don’t need research for everything. For example, you don’t need research to tell you that wine diluted with a good amount of water won’t have the same effect on the drinker. You don’t need research to tell you that substituting chicory for coffee, or milk powder for fresh milk, will yield a less desirable concoction.
        You do need research to ascertain that the substitute is “good enough”, i.e. if the lost quality compared to the savings and convenience, provides better “value” for the dollar. So in this case, they will do research by testing a bunch of kids two weeks after they completed a video class, say, in physics, to those that took the class in person, and find out that both groups can answer the test questions equally well, and when they ask how many want to be astronauts, roughly the same percentage will say that they do. Then they will add obligatory disclaimers about being unable to quantify the quality of the human teachers, and that the adjustments made for children’s socioeconomic status may not be accurate, and finally recommend that further study is needed, but the results look very promising for reducing the cost of higher education.

        That’s what they did in every “industry” and that’s what they will do in the non-industries of education and health care, and that’s how we race to the bottom in quality of everything, and to the top in “value”, because it seems that we cannot take hard cash out of consideration in anything we do.

        Does that mean that one cannot enjoy an occasional video class on a particular subject of interest? No, it does not. It does however mean that we should not flip the system on its head just to make it cheaper in the short run and most likely ruinous for the long haul, and it means that we need to quit speaking about “value” as a code word for appeasing the masses.

        • JR

          Flipped classrooms didn’t start as a way to save money, they started as a way to save students.

          In one school, 50% of students failed English, 44% of students failed Math. After implementing a flipped classroom, 19% of freshmen failed English, 13% of freshman failed math. In the United states, only about 2/3 of high school freshman graduate from high school.

          http://www.knewton.com/flipped-classroom/

          I don’t think a “flipped visit” is right for every patient. It seems that in a field like pediatrics, where there is a desire to provide “education” as well as a checkup, it has merit.

          Course – I’ve been assigned to go read a book before to learn more about my medical condition. I thought, for me at least, it was a good decision.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Yes, I am not surprised that the industry is publishing infographics attesting to its own success. Are you?

            Here is a little bit of additional information about the virtues of flipping everybody over to where we can see them really well http://www.politico.com/story/2014/05/data-mining-your-children-106676.html

            Reading books, or reading peer reviewed articles and journals online is very different and it’s a great way to educate oneself whether in general or about health. There is a huge difference here…..

          • JR

            That article doesn’t have anything to do with watching videos on youtube at home and doing homework on paper at school in a classroom with the assistance of the teacher…

            Not to say it’s not a valid criticism of online courses or computer learning. But this article was about having parents read up on some info at home so they are ready with questions when they come into the office.

            I recently learned that the requirement for kids to get a checkup for school isn’t a letter to the school stating the kid got a checkup. It’s the medical information that is a result of the checkup. Schools are storing kids medical information directly, and it’s been going on for a very long time with no one questioning it. Yikes!!

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            We have strayed miles off the OP, but hey, that’s why forums like this are cool :-)
            My kids school asked for immunization records and clearance to play sports. Nothing else. You can get immunizations records now from state registries (meaningful use requires reporting). Either way, schools have always had lots of paper information on kids, but when stuff is on paper, it is extremely difficult to monetize, and the same is true for medical records.
            I for one can see how Star Trek technology can be beneficial to us all, but I am also reminded that the concept of “money” or wealth, does not seem to exist in those sci-fi utopias that our techie entrepreneurs are forecasting. Perhaps we need to work that kink out first by getting rid of money :-)

            As to coming prepared to the doctor’s office, I couldn’t agree more. I just have an allergic reaction to “flipping” (seems sort of flippant to me :-), and to dumping ever increasing responsibilities (and costs) on people who can ill afford to bear the burden.

          • JR

            This form is required for attendance to Chicago Public Schools, especially check out page 2:

            http://www.idph.state.il.us/health/vaccine/child_hlth_forms/Child_Hlth_Exam_Cert.pdf

            They want to have your 9th graders last menstrual period on file, because I’m sure they need to know that.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Oh wow! Our schools make their own forms and other than immunizations and TB, in our district it’s just a bunch of blank comment lines and a place for a physician signature saying she examined the kid and all is well.
            You’re welcome to cross the river to our side :-)

        • HJ

          No research? Really? Something as complex as learning is compared to diluted wine?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            That was an exaggeration…. Don’t worry, there will be plenty of research, and it’s going to conclude that video watching is as good as having Socrates be your teacher, and all we need in schools is high-school graduates, trained for a couple of months to provide student-centered homework assisstance, and therefore there is no need to spend fortunes on salaries for overqualified teachers. At least for the kids of the 99% who can’t afford University educated teachers, or Medical School trained doctors, or made to order suits, etc. etc. etc. After all, it’s not like these kids, destined to be our “workforce”, would ever become “leaders” of anything significant….

          • HJ

            I am not sure what your point is. Education should always be Socrates imparting information to the few that have a learning style that is able to absorb the lecture?

        • TheresaWillett MDPhD

          I agree that teaching, and good doctoring, is as much about inspiration as basic education. As someone who hated school ( I know, ironic), I would have probably enjoyed the flipped model. The key is offering options, which unfortunately our mega systems just cannot tolerate. I love it when families come in ready to discuss things in more depth, but I also enjoy being able to explain basic things to those without internet ( they do exist). I firmly believe that most visits should have 30 min of my time, but the system as it stands will not pay for that. Just like with schools- when teachers are burdened with parenting/babysitting kids in the classroom, how can they have the time/energy to try to inspire each individual. Clearly I am not offering any useful suggestions, but I think the flipped classroom may be equally valuable to the classical one, just like for some families the ‘flipped’ visit could be.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I do agree that there are many models that we should explore and use. My concern derives from our reasoning for implementing change. We say that the system is not allowing 30 minutes visits, and we then accept that as a fact, and come up with substitutes for the 30 minutes visit. Why not just come up with a way to have 30 minutes visits? Wouldn’t that be the simplest and cheapest solution in the long run?
            And once we got that back in working condition, we can add all sorts of flips to suit every preference… I would say the same goes for education, although the issues there are much deeper. I just think that our problem is not that the “old ways” didn’t serve us well, but that the old ways were destroyed, and we need to stop and reverse the destruction process first.

          • TheresaWillett MDPhD

            Exactly- I very much appreciate that you are willing to keep asking the most basic yet unanswered question- But Why? Why 10-15min visits? Why keep letting the insurers be the middle man? Why allow the status quo? I have been asking that question since med school, and while I have used it to try to stick up for others, it turns out few stick up for me. I keep leaving jobs that on the surface are fine, but in reality are soul-sucking micromanaged nightmares of apologizing for things outside of my control. But why? Why do not more docs have a good look in the mirror and reassess what they signed up for? Why not support those who bring up the questions and suggest answers? Very baffling state for a supposedly intelligent profession!

    • DeceasedMD1

      It only takes as far as nursing in the hospital to see the consumerism. Pts are regulated to watch a video for fall prevention. The ad on the wall, ” Please call, don’t take a fall”.

      I did not know nursery rhymes were an effective treatment strategy. Meanwhile nurses are too busy following regulations and to see if the customer is satisfied. All effective distractions for pt care.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Do you “void the warranty” if you don’t watch the video? :-)

  • Mike Painter

    Justin, Great post. Love your ideas-and never fear…you are in good company. If you haven’t already take a look at our Robert Wood Johnson Foundation site, Flip the Clinic: http://fliptheclinic.org/. Our initiative is devoted to the idea that health professionals and patients can and should come together, propose and try all sorts of ideas to improve the relationship between health professional and patient. It’s true that the initiative came from discussions we were having on another RWJF project with the Khan Academy. See that one: http://www.khanacademy.org/science/health-and-medicine. One kind of flip is precisely as you describe-simply acknowledging that online education resources are available and people are going to use them–why not take advantage of that and then use the precious human-to-human time in the best possible way? There are many other flips too–see some of the examples folks are beginning to suggest. And please join our Flip the Clinic community–we’d love to have great docs like you there. Great post. Thanks again.

  • MW

    Personally I think this is a great idea. Sometimes the information our pediatrician is telling us at the visit is overwhelming or I have other issues on my mind and find that my mind is wandering. I like the fact that I could read through what to expect before hand and then dictate what I’m concerned about with my baby. Also, there might be some things that I may not be concerned about but maybe should be and we may never talk about it.