Teaching pathology what students learn
- 1. Robert Boorstein, MD, PhD
- 2. History of American Medical Education Grounding in Basic Science Analytical Reasoning Clinical training in academic centers Research A moral dimension
- 3. A Schizophrenic Self Portrait: NEW YORK — The United States’ standing in the world ebbs and flows, but one thing remains strong: the reputation of its medical schools and the physicians they produce. Whatever the international criticisms of its financial regulatory system or past foreign policy, the United States has long been perceived as the go-to place for state-of-the-art medical care. http://www.nytimes.com/2009/04/29/ education/29iht-riedmedus.html?_r=1&ref=education
- 4. American Medical Education 100 Years after the Flexner Report ““The need for a fundamental redesign of the content of medical training is clear.” Our approach to education is inadequate to meet the needs of medicine. Ossified curricular structures, a persistent focus on the factual minutiae of today's knowledge base, distracted and overcommitted teaching faculty, archaic assessment practices, and regulatory constraints abound. These challenges threaten the integrated acquisition of technical knowledge and contextual understanding, the appropriately supervised mastery of practical skills, and the internalization of essential values that together make for an informed, curious, compassionate, proficient, and moral physician. “ http://content.nejm.org/cgi/content/full/355/13/133
- 5. Multiple cycles of curriculum reform, based on premise that there are major systemic failings in education, with direct but remediable consequences to health care.
- 6. Medical Education is characterized by ongoing change Patient centered education Small Group Teaching Problem Based Learning Horizontal Integration Vertical Integration Recognition of diversity Social Context Life-long learning Mastering information technology Just in time teaching Team based learning
- 7. Is change per se a desirable thing? 'Change Simply for the Sake of Change Is an Abdication of Leadership‘ John Luke Jr, chairman and CEO, MeadWestvaco.
- 8. Ongoing change is integral to success Innovation: Innovation is the heart of our school. We are open to new ideas from faculty, students, staff and others. We seek out new ideas and will evaluate them with open minds in order to continue to improve the efficacy of health care and the health system. http://www.thecommonwealthmedical.com/oth/Page.asp?PageID=OTH 000267
- 9. Pathology Education at NYUSOM Second year experience Spans the entire second year Integration with historic units in microbiology, pharmacology, medicine, and parasitolology.
- 10. The transition Pathology, the study and Pathology, the understanding of disease acquisition and use of diagnostic information
- 11. The Bottom Line Most of what students learn about diagnostic laboratory medicine is learned from point of view of internal medicine.
- 12. When to teach Clinical Pathology: After 3rd year? Students have been exposed to many clinical settings. Developing a sense of natural history of disease Have some understanding of how much they don’t know. Looking for practical information Looking for intellectual underpinnings to unify concepts and facts
- 13. Utilization of Clinical Laboratories in Medical Practice. 2 week course Meets daily for two hours 24-40 students in two to three sections. Case based teaching, cases prepared and edited by faculty and course director. Students read primary literature and lead discussions presentations
- 14. Specific clinical pathology issues Handling of large amounts of clinical information Comfort with quantitative results and with results expressed as risks Understanding the rapid pace of change in laboratory medicine
- 15. Standards for success in medical education For most exams, 75-85% on tests. In contrast, for medical practice, systems are moving toward 100% performance standards on defined task.
- 16. Evaluation of students Evaluation of the class as a whole, rather than of individuals. In class “exam” using audience response system, before and after.
- 17. Issues documented by pretest Small minority cannot accurately demonstrate knowledge of clear clinically relevant activity . Large minority, or majority, has learned something contrary to what we teach. Large minority, or majority, has misunderstood major principle, especially involving, statistics or time. Broad variations in understandings without intent, including unsupported consensus or unsupported variation.
- 26. Microbiology
- 39. Hematology
- 44. Cytology
- 47. IsHPV DNA Testing Positive with Normal there a correct answer? Cytology…The use of HPV DNA testing as an adjunct to cervical cytology for women aged 30 years and older increases the sensitivity of cervical cancer …Repeat HPV DNA testing combined with cervical cytology in 12 months appears to be reasonable for patients in this group. http://www.guideline.gov/summary/summary.aspx?doc_id=13311&nbr=6755&ss=6&xl=99 9
- 54. Cancer
- 64. Frozen Sections
- 70. Algorithms
- 75. Monitoring
- 80. Screening
- 101. Conclusions Students entering their senior year have measurable gaps in knowledge, including knowledge of specific behaviors with implications specifically related to processes, cost, and utilization, A course given at the begining of the senior year of medical school can be used to identify such gaps. The success of the medical system is based on the aggregate performance of all physicians. A standard of 100% in some areas is appropriate.
Editor's Notes
- #43: Only 79% gave the generally accepted answer.
- #44: Only 79% gave the generally accepted answer.
- #46: It is not clear the actual practice at NYU. Published guidelines (below), reiterated in January 2009, would favor answer 3. If answers 2 and 4 are in fact the actual practice, it would be interesting to know the rationale.“Many women screened with a combination of HPV DNA and cervical cytology will test positive for HPV DNA and simultaneously have a negative cervical cytology. The risk for undetected CIN-2/3+ for patients with such a combination of screening results is quite low, with published study results varying from 2.4% to 5.1% [A]. Based on this low risk for CIN-2/3+, repeat HPV DNA testing combined with cervical cytology in 12 months appears to be reasonable for patients in this group.” http://www.guideline.gov/summary/summary.aspx?doc_id=13311&nbr=6755&ss=6&xl=999
- #47: It is not clear the actual practice at NYU. Published guidelines (below), reiterated in January 2009, would favor answer 3. If answers 2 and 4 are in fact the actual practice, it would be interesting to know the rationale.“Many women screened with a combination of HPV DNA and cervical cytology will test positive for HPV DNA and simultaneously have a negative cervical cytology. The risk for undetected CIN-2/3+ for patients with such a combination of screening results is quite low, with published study results varying from 2.4% to 5.1% [A]. Based on this low risk for CIN-2/3+, repeat HPV DNA testing combined with cervical cytology in 12 months appears to be reasonable for patients in this group.” http://www.guideline.gov/summary/summary.aspx?doc_id=13311&nbr=6755&ss=6&xl=999
- #49: 16% of students would recommend not acting on a high grade squamous epithelial lesion. Per guidelines, colposcopy would be indicated. http://www.guideline.gov/algorithm/6755/NGC-6755_1.pdf. Most guidelines would say that the HPV was not indicated, and thus is a distractor. Failure to act would probably be a medical legal issue. Fortunately, there should be redundant steps requiring communication between the lab to determine if follow up has occurred.Only 8% gave the less favored answer last year.
- #50: 16% of students would recommend not acting on a high grade squamous epithelial lesion. Per guidelines, colposcopy would be indicated. http://www.guideline.gov/algorithm/6755/NGC-6755_1.pdf. Most guidelines would say that the HPV was not indicated, and thus is a distractor. Failure to act would probably be a medical legal issue. Fortunately, there should be redundant steps requiring communication between the lab to determine if follow up has occurred.Only 8% gave the less favored answer last year.
- #56: 27% of students would use DNA based technologies to measure protein.Last year, 43% of students answered PCR AND 14% said ISH, so this is actually an improvement.
- #57: 27% of students would use DNA based technologies to measure protein.Last year, 43% of students answered PCR AND 14% said ISH, so this is actually an improvement.
- #63: No “correct” answer was expected. It is clear there is a wide variation in answers and no clear standard.Last year, 80% said flow cytometry so it would appear there is an evolving move towards PCR based tests.
- #64: No “correct” answer was expected. It is clear there is a wide variation in answers and no clear standard.Last year, 80% said flow cytometry so it would appear there is an evolving move towards PCR based tests.
- #66: JCAHO has a clear standard of 20 minutes, which was the correct answer for 22%, about chance. 22% said under 5 minutes, which would almost be impossible under any conditions, and 50% said under 10 minutes, which would be difficult under the most ideal conditions.
- #67: JCAHO has a clear standard of 20 minutes, which was the correct answer for 22%, about chance. 22% said under 5 minutes, which would almost be impossible under any conditions, and 50% said under 10 minutes, which would be difficult under the most ideal conditions.
- #68: Only 16% of students gave the answer desired, or 99% specificity. Many published studies document 99% specificity and one strives for 100%. Every false positive would have serious consequences both from a clinical and medical legal stand point. If one thinks about it, 95% specificity would be 5% false positives, and 75% specificity would be 24% false positives. If the result of a false positive is removal of an organ, say breast, or stomach, that would be horrendous.Last year students answered “above 99%” 60% of the time.
- #69: Only 16% of students gave the answer desired, or 99% specificity. Many published studies document 99% specificity and one strives for 100%. Every false positive would have serious consequences both from a clinical and medical legal stand point. If one thinks about it, 95% specificity would be 5% false positives, and 75% specificity would be 24% false positives. If the result of a false positive is removal of an organ, say breast, or stomach, that would be horrendous.Last year students answered “above 99%” 60% of the time.
- #70: 6% indicated that a sentinal lymph node biopsy is done to grade a tumor, showing a lack of understanding of the difference between grade and stage.This is an improvement compared with last year, when 20% of students gave the incorrect answer.
- #72: Most pathologists recommend troponin only. This year, 68% of students concurred with this recommendation, an improvement from 53% from last year.
- #73: Most pathologists recommend troponin only. This year, 68% of students concurred with this recommendation, an improvement from 53% from last year.
- #74: 78% of our students would order an amylase in addition to lipase for suspected pancreatitis. Last year 60% gave this answer.Almost all sources recommend against the use of amylase, or point out the lack of utility. Pathologists have been trying to restrict the use of amylase for many years, based on data 15-20 years old. It would appear to be that most of our students are taught otherwise. Regarding selection of these tests, from wikipedia:"It is usually not necessary to measure both serum amylase and lipase. Serum lipase may be preferable because it remains normal in some nonpancreatic conditions that increase serum amylase including macroamylasemia, parotitis, and some carcinomas. In general, serum lipase is thought to be more sensitive and specific than serum amylase in the diagnosis of acute pancreatitis" [3] "Although amylase is widely available and provides acceptable accuracy of diagnosis, where lipase is available it is preferred for the diagnosis of acute pancreatitis (recommendation grade A)"[4] Most (PMID 15943725, PMID 11552931, PMID 2580467, PMID 2466075, PMID 9436862), but not all (PMID 11156345, PMID 8945483) individual studies support the superiority of the lipase. In one large study, there were no patients with pancreatitis who had an elevated amylase with a normal lipase [5]. Another study found that the amylase could add diagnostic value to the lipase, but only if the results of the two tests were combined with a discriminant function equation [6].
- #82: 19% made a clearly wrong answer on a question that is intrinsic to any screening program. 100% answered correctly last year.
- #83: 19% made a clearly wrong answer on a question that is intrinsic to any screening program. 100% answered correctly last year.
- #85: It is fairly clear that our students understanding of what a positive PSA means is quite variable. The question is slightly poorly worded, so a result would depend on the population. If one were grading this question, I would view 10% (23%) and 25% (29%) as reasonable answers if the question were rephrased as, “Doc, if my PSA is positive, what is the chance I have cancer”. The answers of 5% (10% of students), and 95% (6% of students) are clearly wrong.Performance is much better than last year, where 33% chose 5% and 13% chose above 95%.
- #87: Limited evidence of effectiveness, most recently reiterated in 2 NEJM articles. http://www.nejm.org/perspective-roundtable/screening-for-prostate-cancer/Urologists continue to recommend this testing.
- #88: Limited evidence of effectiveness, most recently reiterated in 2 NEJM articles. http://www.nejm.org/perspective-roundtable/screening-for-prostate-cancer/Urologists continue to recommend this testing.
- #89: General perceptions are that this answer is True. Recent studies have challenged this.
- #90: Evidence for cost effectiveness of FOBT and sigmoidoscopy is at least as good as Colonoscopy.
- #91: Evidence for cost effectiveness of FOBT and sigmoidoscopy is at least as good as Colonoscopy.
- #92: Evidence for cost effectiveness of FOBT and sigmoidoscopy is at least as good as Colonoscopy.
- #96: There is literature of mixed quality supporting answer 7.
- #97: There is literature of mixed quality supporting answer 7.
- #100: 100% gave the expected answer last year.
- #101: Interesting. Last year 28% reported the lower two categories, compared with 52% this year.