etc. This whole process takes years. So
CRMs, about eight to 10 students
how many times has medical technology
are presented with clinical cases by a
doubled in that time frame? Educators
moderator who leads the discussion
still refer to textbooks, but as references,
on history, physical, labs, imaging, etc.
not as primary education material.
The model used is a version of clinical
A man walks into a bar in New
reasoning called a “mind map,” and
Orleans and asks for a Corona and
it stresses differentials and necessary
three hurricanes. The bartender hands
testing and imaging. Grading is based
him the bill—$20.20. Yes, the COVID-19
on participation. As the “clinical expert,”
pandemic has changed things, possibly
I rotate to all the small groups and
permanently. Virtual medical education
answer questions. This is where I get to
is the current modus operandi. Zoom,
meet students I have never seen before.
WebEx, Skype, and Join.me, to name
So, if there are no textbooks or
a few, are the classrooms today. Right
lectures, what do the students do to
now, learning clinical skills is generally
prepare or to learn? Good question!
virtual. Inconceivable but true—not
Instead of scheduled lecture time,
hands on but virtual patients. Not
regular time is scheduled during
entirely new, just brought to the forefront
their day to “study.” Faculty prepares
due to the pandemic.
Directed Student Activities (DSAs). The
Over the past several years, the
DSAs include society guidelines, videos,
lecture (that four-letter word again)
online sites like Up To Date and more.
hall has been sparsely filled unless
Here textbooks are listed, usually as
attendance is mandatory, as some
reference rather than test material. As
medical schools still do require,
you can imagine, the students are very
or if an in-person quiz is on the
resourceful and tell me about sites they
schedule. Before attendance began
find on their own that support their
to drop, medical educators made the
learning process. The list I have been
classroom an interactive session and
informed about and use to refine my
the iClicker was used to respond to
DSAs are Baby Robbins, Pathoma,
questions. However, with Power Point
First Aide, Sketchy Medicine, Get Body
presentations now online before the
Smart, Picnomics, and Hardin MD.
lecture is given, and voice over with the
As you can imagine, the time spent
Power Point, why go to the lecture hall?
by faculty to screen all these sites is
Pull up the Power Point whenever you
overwhelming. Since our curriculum is
want, play it at 1.5 to 1.8 speed, and
problem-based, symptoms or problems
listen to it twice. The thought is that
are the topics of our DSAs. Since I am
“
the classroom is wasted time, and you
a gastroenterologist, my topics are
avoid being called on in class.
abnormal liver chemistries (not called
There is still in-person training. I teach
LFTs anymore), nausea and vomiting,
in the second year, which includes
dysphagia, GI bleeding, constipation,
small group sessions called Clinical
diarrhea, and so forth. Can you imagine
Reasoning Modules (CRMs). In the
the time needed to condense these TARRANT COUNTY PHYSICIAN (31)
January/February 2021
topics into DSAs that are current and
learnable using this format?
To worsen the situation, clinical
clerkships have been adversely affected
by the pandemic. Many institutions
banned medical students from direct
patient contact, and in some instances,
from entry into hospitals or surgery
centers. Virtual patients were used to
teach clinical skills devoid of in-person
contact or interviewing. When will they
get to see patients in person and learn
bedside and in-office clinical skills?
Who knows with the recent COVID-19
surge. Some have learned telehealth
clinical care, which in some cases may
be here to stay. Recent legal issues
about student participation in clinical
care have also started to cloud the
problem. How will all this impact future
clinical skills?
So, all these issues in medical
education will indeed have an impact
on health care. Medical educators have
their work cut out for them in the new
learning environment compounded by a
seemingly never-ending pandemic. Not
only are medical students educated to
pass boards and clinical competencies,
but to become lifelong learners. They
must learn without DSAs and with
doubling of medical technology every
several months. When do they learn
cost restraints, physical exam, and other
competencies?
I know that this essay is called the
Last Word, but this is hardly the last
word on this topic. Hold on to your
hats—this is a new world. Who knows
what the new normal will be? As for me,
the Last Word is that knowledge can be
communicated, but not wisdom.
I HAVE BEEN AROUND A LONG TIME AND SEEN
A LOT OF CHANGES, INCLUDING MONUMENTAL
ONES IN MEDICAL EDUCATION, FROM THE
CLASSROOM TO CLINICAL BEDSIDE CLERKSHIPS.