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Teaching Hematology to Second-Year Medical Students: What Are We Doing, How Are We Doing It, and Can We Improve? How Medical Education Has Changed Over the Decades. William E. Winter, MD University of Florida Departments of Pathology and Pediatrics.

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slide1

Teaching Hematology to Second-Year Medical Students: What Are We Doing, How Are We Doing It, and Can We Improve?

How Medical Education Has Changed

Over the Decades

William E. Winter, MD

University of Florida

Departments of Pathology and Pediatrics

slide2

How am I involved in teaching hematology?

  • 2nd Year Medical Student General and Systemic Pathology Course Director, 2004 – > present
  • Background
  • - Pediatrics, Pediatric endocrinology
  • Clinical Chemistry

True confession - I am not a clinical hematologist or a hematopathologist

- I teach in hematopathology

- Reading a CBC

- Hematopoiesis

- Laboratory coagulation testing

- Blood bank (basics)

slide3

2008 - The Times They Are A Changin’. . . .

2009 - The Times They Have Changed

Come mothers and fathersThroughout the landAnd don't criticizeWhat you can't understandYour sons and your daughtersAre beyond your command

3

slide4

UF College of Medicine

2000 2009

Medical Students

Number/class 120 130

M/F ~50:50 ~50:50

“Epidemiology”* Gen X Millennials

DOB 1960-1979 1980-2000

* Teachers: Baby Boomers: 1946-1964 (US Census Bureau)

slide5

Have medical students changed in the last 10 years?

  • Yes! Medical students have changed in the past ~10 years:
    • Independent: work at their own pace; multitask
    • Less appreciation for hierarchy
    • equality of student and teacher (disrespect?)
    • yet: interested in social justice, poverty, inequity
    • On-demand information availability using all possible communication media interfaces
    • Internet, youtube, facebook, iPhone
slide6

How is our present hematopathology course organized?

Contact hours20002009

Benign hematology:

Lecture 6 5

Lab 4 (2) 2 (2)

Pt pres. 2 1

Coagulation:

Lecture 4 5

Lab 0 1 (1)

Neoplastic hematology:

Lecture 5 8

Lab 6 (3) 3 (3)

----- -----

27 25

(-)

Added

1 lab

No change

Decr. total hrs.

(_) sessions

slide7

How is our present hematopathology course organized?

Contact hours20002009

Benign hematology:

Lecture 6 5

Lab 4 (2) 2 (2)

Pt pres. 2 1

Coagulation:

Lecture 4 5

Lab 0 1 (1)

Neoplastic hematology:

Lecture 5 8

Lab 6 (3) 3 (3)

----- -----

27 25

10 h ------- > 6h

(_) sessions

slide8

Questions of importance:

If there is more to teach, how could we teach more in less time?

How could we reduce lab time without reducing content?

Why should students participate in lecture and lab?

COURSE REVISIONS -- > were not directed at reducing contact time -- > reduced contact time was a result of our course “renovations”

slide9

If there is more to teach, how could we teach more in less time?

  • Students have a better understanding of molecular biology than in the past(HS students study recombinant DNA technology & molecular biology)
  • Teach from the physiology-- > pathophysiology (disease follows the physiology)
    • Benign hematology is extremely logical
    • Neoplastic hematology is becoming morelogical
  • Lectures and labs emphasize problem solving (recall is used as a “tool” to solve problems and is not an educational end in itself)
slide10

If there is more to teach, how could we teach more in less time?

4) Reduced the number of lecturers (selected better educators)

5) Frequent references to material previously taught

(e.g., inflammation & repair, immunology & immuno-pathology) (educators know the student’s course work) [“integration”]

slide11

If there is more to teach, how could we teach more in less time?

6) Teach what is important for an MS2 (and little more)

- Refer to a standard MS textbook (Robbins)

7) Emphasize clinical presentations and differential diagnosis

8) Treatment is not the 10 goal of the pathology course

- Treatment is discussed but specifics should be discussed in pharmacology, oncology, MS3+

slide12

If there is more to teach, how could we teach more in less time?

Linked labs directly to topics / problem-solving focus

Neoplastic HP

Introduction to HP (technologies)

Lymphadenopathy/ lymphoma (I)

Lymphoma (II)

Lab: Lymphadenopathy/ lymphoma

Leukemias (I)

Leukemias (II)

Lab: Leukemias

MDS/MPD

Lab: MDS/MPD

Problem solving

Problem solving

Problem solving

slide13

What is “problem solving?”

An example from the coag lab --- >

A 5 y/o boy presents with a swollen, tender knee 12 hours following trauma. The knee is taped and bloody fluid is removed. Is this most consistent with a defect in primary hemostasis or secondary hemostasis?

Secondary hemostasis

slide14

For the 5 year old boy, what 2 clotting tests are most important to initially order?

PT and aPTT

Reference interval (sec)

PT 10.5 - 13.5

aPTT 23 - 33

Pt result

12

42

What factor(s) could be deficient, dysfunctional or inhibited?

Factors XI, IX, VIII

Why isn’t FXII included on this list?

Factors XII deficiency does not cause bleeding

slide15

If there is more to teach, how could we teach more in less time?

Link: Physiology – Lab testing – Pathophysiology –

Pt Evaluation

Coagulation

Introduction to coagulation testing

Pathophysiology of bleeding diatheses

Pathophysiology of thrombotic disorders

Approach to the patient who is bleeding

Approach to the patient with thrombosis

Lab: Coagulation cases

Problem solving

slide16

If there is more to teach, how could we teach more in less time?

Physiology – Lab testing – Pathophysiology

Patient presentation ----------------------- > Diagnosis

Therapy/

monitoring

slide17

How could we reduce lab time without reducing content?

Contact hours20002009

Benign hematology:

Lecture 6 5

Lab 4 (2) 2 (2)

Pt pres. 2 1

Coagulation:

Lecture 4 5

Lab 0 1 (1)

Neoplastic hematology:

Lecture 5 8

Lab 6 (3) 3 (3)

----- -----

27 25

Total time in lab: 106

(_) sessions

slide18

How could we reduce lab time without reducing content?

Improved the relevance of the labs -- > the labs are all case-based and authentic, diagnostic, problem-solving exercises

Labs: 2000: Histopathology (+)

ASH cases (too complex for MS2’s)

2009: De-emphasized histopathology*

Created clinical cases appropriate for MS2’s

- ex.: benign hematology: M. Zumberg, MD

* we are training generalists (not pathology residents)

slide19

How could we reduce lab time without reducing content?

Cases: Powerpoint format (“serial reveal”)

Socratic method: Question and answer

Not all answers provided during lab*

Students make diagnostic decisions

* Faculty/staff available to provide answers

slide20

How could we reduce lab or lecture time without reducing content?

  • Provide self-taught exercises [Millinneals are independent (?)]
  • Examples:
    • Aplastic anemia H/O (3 pages)

What is aplastic anemia?

What are the consequences of aplastic anemia?

What is the appearance of the BM in aplastic anemia?

What are the causes of aplastic anemia?

What is an idiosyncratic reaction?

What is the differential diagnosis of pancytopenia?

What is pure red cell aplasia?

What is a myelophthisic anemia?

slide21

How could we reduce lab time without reducing content?

  • Provide self-taught labs
  • Examples:
    • Anemia self study
slide22

Case 1

A woman of reproductive age reports menorrhagia and tiredness. Her heart rate is 105 bpm. She is pale. Her stool tests negative for occult blood. Pertinent results from her CBC are displayed below.

Reference interval Pt results

RBC count 4.15 - 4.90 x 106/mm3

Hgb (females) 12-16 g/dL

Hct (females) 37-48%

MCV 80-100 fl

3 x 106/mm3

9 g/dL

27%

75 fl

slide23

IS THE PATIENT ANEMIC?

YES

NO

HOW DO YOU DESCRIBE HER ________?

MICROCYTIC

NORMOCYTIC

MACROCYTIC

ANEMIA

“Clinical decision making”

slide24

Why do our labs emphasize problem solving and not recall?

Problem-solving:

medicine is “all about” solving & treating problems

key to learning: active learning

- valid (vital!) for clinical care of patients

- valid for exam (case-based, non-recall Q’s)

Testing will drive learning

slide25

How could we reduce lab time without reducing content?

All students work in 3 - 4 person teams in pathology (August -- > Feb)

Students are tasked to teach one another

slide26

How could we reduce lab time without reducing content?

All students work in 3 - 4 person teams in pathology (August -- > Feb)

Teams are efficient

W/o excessive # of slides -- > focus on problem-solving cases

Abundant faculty/fellows/pathology residents available to assist students

Reduced lab time: 2 hrs -- > 1 hr

slide27

How could we improve the faculty / student ratio and reduce noise and crowding in lab?

2009: Divided all lab sessions in half

No. students / session

2000 120

2009 65*

* hold 2 lab sessions for each single lab

Faculy-staff / student ratio: DOUBLED!

More efficient use of time -- > reduced lab time

“We can’t do more -- > we need to do better!”

slide28

How could we reduce our contact hours AND improve the course at the same time?

Provided sufficient time for important topics

Coagulation

Multiple myeloma

Myelodysplastic syndromes / myeloproliferative disorders

Added: coagulation testing lecture

Added: coagulation lab

Taught in immunology: SPE, IFE

MGUS versus MM vs. Waldenstrom

1 lecture –split-- > 2 lectures

slide29

Why should students participate in lecture and lab?

  • Concepts for your consideration:
  • Education is a “real time” experience
  • W/ an interactive lecture style, students must think!
  • Listening to the lecture at 2x speed -- > enforces “consumption” of facts and not “processing” of information
  • Active learning -- > engagement through problem solving
slide30

Why should students participate in lecture and lab?

Concepts:

Lab: You must be able to work successfully in groups (e.g., lab teams)

Recorded lectures can be available as a supplement to attendance -- > does not replace attendance*

* You can’t take you patients home; expectation of attendance must begin before 3rd year (professionalism)

slide31

Summary

Physiology

V

Pathophysiology

(+)

Patient’s Hx / PE

V

Differential diagnosis

v

Definitive testing

V

Diagnosis

V

Therapy

Goal of 2nd year pathology:

Train students to undertake this process!!!