Month: May 2016

“the secret of education is respecting the pupil.” – Ralph Waldo Emerson

Remember the rows of desks in public school? Remember the chairs attached to them with a bar on one side, as if to reduce the number of possible projectiles a child could manage to lift should an uprising occur – chairdesks, one word, filling the centre of a room lined with chalk boards, bristol boards, and cubbies for your winter boots. I had long forgotten the look of an elementary school classroom. Until, that is, I had the pleasure of attending the 25 year anniversary of the opening of my public school, Morrish PS.

25 years ago, I was in junior kindergarten, and Highland Creek Public School was bursting at the seams. Just a few months after starting the terrifying ordeal of boarding a long, yellow school bus alone each morning, half the school population, led by police escort, hiked the 2 kilometers to our new home, Morrish.

My JK teacher, who would (by her own design) also be my Grade 8 teacher, was Jan Griffen, an artist at heart with a smile that couldn’t be wiped away by even the most annoying children or angry parents. It was in grade 7 that Mrs Griffen lobbied my father to convince me to accept the role of Oliver in the school’s annual music theatre production “Oliver Twist.” Terrified of public speaking, I declined. Seeing Mrs Griffen last week, I couldn’t help but confess that one of my greatest regrets to this day is having turned down the chance to belt out “oom pah pah” in front of an audience who would applause regardless of my pitch.

How she realized years before I my love for the stage is beyond me. I would, of course, become an actor later in high school, even earning a paycheck parading around the city as part of a 6-member community theatre troupe, and who knows how life’s trajectory may have changed. I’ve always said, after my stint in acting, that “I sold my soul and went to science school,” too scared of the uncertainty (and inevitable poverty) that comes when acting becomes your vocation.

After wailing for what could have been, the two of us immediately broke out into an impromptu “Consider Yourself,” and my regret was never greater.

Next I saw my grade 7 teacher, Mr. Bebbington, who’s first name was John. My memory of Mr. Bebbington would best classify him as a hippie, and this was no less true 25 years later. Mr. Bebbington had us calculate our carbon footprint, annual water usage (read: wastage) and took us on expeditions to forests, fields and ponds where we got to touch nature rather than read about her. But the true value in Mr. Bebbington’s pedagogy came from his constant, unshakable offering of respect towards all the students in the class. He treated us like young adults, and perhaps in grade 7 we were, but it was the first time I felt an adult was treating me not like a child, but as a peer.

I’d had many wonderful opportunities to teach in the last fifteen years; from first aid to swimming to paramedics to undergraduate anthropology students to med students, I’ve often attempted to emulate Mr. Bebbington’s near-peer approach to making students feel welcome, comfortable and embraced.
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In Grade 1, I was segregated to a corner with one other student to read the Toronto Star each morning while the rest of the class learned to read. Anil, a brainiac with reading comprehension skills superseding most adults, would sit beside me as he read the front page. “Interesting situation at the United Nations” Anil would offer, and I would say “yes, very interesting” as I pretended to understand the newsprint.

For months and months I perpetrated what I can now confess was a total scam: I had no idea how to read the newspaper, except for the passages where Anil acted as an interpreter for written-to-spoken word. I suppose Mrs. White, a traditional-looking school teacher if ever there was one, saw potential in me, albeit ahead of my time. Regardless, I can trace the birth of my competitiveness and drive back to Grade 1, in the corner, with the newspaper, trying desperately to live up to expectations. Of course, 25 years later, I’ve refined these traits to compete against only myself, and drive myself to turn my dreams into reality. Thanks, Mrs. White.

Ms. Davies, the charismatic grade 4 teacher who hasn’t aged a day in 25 years, now runs an art gallery up north. We’ve been Facebook friends for years, though haven’t connected in non-avatar form since I left Morrish PS for the scary halls of West Hill Collegiate. Standing beside my lifelong best friend Thomas, she regaled me with stories of our antics, reminded me how I broke one of her mugs (and adhered to her “break one, buy two” etiquette) and couldn’t stop beaming when she heard of the career moves both Thomas and I had made.

Mr Epp never smiled, or so I recall the facial expressions of my Grade 8 science teacher. Whether growing plants in different lighting conditions or refracting light through a prism, science was fun, but not funny under Mr. Epp. With an appearance suggesting that Bill Nye owned a branch of his family tree, Mr Epp was the protoplasm of a science teacher. His green-painted classroom lined with science benches and Bunsen burners, we would funnel in from Mrs Griffen’s class to learn about photosynthesis, physics and other things I don’t remember but are likely evident all around me. Oh, magnets, we definitely did something with magnets.  And we found electricity in lemons.  That was pretty mind-blowing for a grade-eighter.

What I don’t recall Mr. Epp teaching was anything related to the human body, so credit can’t be placed here for my career choices. What struck me at the reunion last week, however, gets Mr. Epp an honourable mention in this post: for a man whose smile I can’t recall, 25 years later it was lighting the room. As students would walk past, he would instantly recognize them, and you could tell that he knew exactly which chairdesk you sat in, and much, much more. The joy he was experiencing hearing of our life adventures was touching, and reminded me what a privilege it is to teach others.

To all my teachers, past and present, thank you for fuelling my fire. Ralph Waldo Emerson once said “the secret of education is respecting the pupil.” For the teachers of Morrish PS, Emerson’s message was their mantra. 25 years later, the pupil still feels respected, and reciprocates that respect a thousand times over.

I’m hanging out on a cliff with this post… if you disagree with me, you’re not alone! Let’s start a discussion.  Comment below and let me know your thoughts.

Pimp (medicine, acronym): “Put In My Place”

Pimped (medicine, historical)): to be asked a question you don’t the answer to for the sake of making you feel small and insignificant.

Pimped (medicine, colloquial): to be taught something new

The word “pimp” is stupid. The phrase “yo, dawg, he just got his ass pimped!” is also stupid. I think Akash said it once. Doesn’t matter.   Recently, medical learners have revolted against the time-old model of medical pedagogy that involves standing in a circle and being quizzed. It shatters confidence and makes people feel vulnerable, they say. It’s for “sport”, others posit. Regardless, it’s application is highly debated by both learners and teachers alike.

Pimping can be bad.

I must admit, it can be awful if done poorly.  Pimping has certainly been used for evil. To shame, to “make an example of” or simply to draw delicious tears to feed the maniacal mind of an old-school physician to pompous to think he (or she, but let’s face it…) should occasionally leave his narcissistic mind, are all examples of pimping-gone-wrong. I should say that the most horrifying evisceration of an intern I have ever seen was executed by a female consultant, and at my institution the male consultants seem to be more vile in their treatment of learners and housestaff than the women.

But, ultimately, it is the culture, not gender, that predispose some of the smartest people in the world to pimping in the dumbest of ways. But most consultants, I would suggest, pimp appropriately. It is the learners who need to change.

Pimping can be good.

You see, I like to be pimped. It lets me know what I am expected to know, and whether or not I know it. It has identified flawed mental frames (normal speak: ideas) so deeply installed in my brain that a hurricane could not shake them. It has, quite simply, made me better at what I do.

When done well, the pimper feels like a mentor, a big sister, a teacher. But pimping is often done wrong. It shatters my confidence. It isn’t fun. It feels like the pimper is out to get me, judging me, hating me.

These episodes of “bad pimping” have given a negative to connotation to any type of pimping at all. It seems to me that if someone senior asks someone junior a question, the whole room of learners turns red with anger as their eyes roll as if the questioner were trying to light a fire with flint.

 

Pimping is misunderstood by learners

Learners, so coddled by a societal shift in education in general, and medical education along with it, feel insulted to dawn upon the idea that they might not know the answer to a question. To summarize what could turn into a rant, learners seem to think the teacher should teach until the learner has learned, that learning is passive. But learning takes work, and I think learners today don’t work as much as the learners of yesterday.

(If you read through the lines, I’m calling modern learners lazy. I don’t mean all modern learners, but I am comparing them to learners of the past, generally. This theory of mine blames societal and cultural shifts detached from medicine; I attach no negative feelings to any learners, past or present.)

Now, there are better ways to create new doctors than lectures, textbooks, and public humiliation. My MedEd Heroes can speak more elegantly than I on this topic (although it is likely to be the topic of a future post, which they will think is “cute”). But to prevent becoming tangential, lets just say that at some point in time a medical learner will need to leave the black-and-white security of a (flipped) classroom and enter the grey clinical environment, where people aren’t textbooks and procedures are harder than YouTube would have you believe. And at that point, someone smarter than you should, must, ask you questions.

Why is pimping essential to the learner?

• To get to know YOU. Each learner is unique. They have unique development needs. You don’t want me treating you like everyone else.
• To diagnose your difficulty and keep you safe. See, most of us make the same mistake as the last learner, and good preceptors can anticipate your challenges.  Maybe you think the vein is medial to the artery. (Sometimes it is, like when starting a femoral line, but sometimes it isn’t, like when starting a jugular line). By questioning you, I can get to that misconception, give you a trick or two to fix it, and watch you succeed.
  

  How I make sure I never cannulate an artery when placing a central line:

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• To advance your abilities. A house is made of bricks. Adding one brick at a time will help you become a competent physician. If I give you one brick, you can place it on whichever wall needs building right now. If I give you some drywall, you won’t know where to put it yet; it will get wet, or damaged, or you’ll just forget all about it by the time you’re finishing the basement.
• To frame your knowledge. My head has a lot of knowledge in it. None of it is useful at 4:00am during a cardiac arrest. What is useful are the algorithms, mind maps and strange stories I have created to organize that knowledge. When I shock a heart with a defibrillator, I’m not thinking about the joules travelling through the thorax or the cardiac action potential, or sodium and potassium and calcium and actin and myosin and lactate and the kreb cycle. I’m thinking “2 minutes is up, I see VF. Clear!” I became a clinician years after becoming a paramedic when a very smart critical care paramedic named Jonathan Lee drew a triangle on a piece of paper that he pulled out of the garbage can.  Five minutes later, shock made sense to me.

• 

• To keep you on track. Because we all like to binge-watch on Netflix.
• To challenge you. If you don’t like it, tell me, and I’ll stop. But I like to be challenged. I like to be confused and unclear and then set off on a mission to figure it out for myself. I like to know “why” or “why not”, the “what if” and the “unless”. I’m so engaged in sorting out my own frames that I’ll call out obfuscation by saying “Wait, but you just said…” This aggressive learning style has gotten me in trouble for being too “confident” or “cocky” or “questioning my attending” but has served me well when it comes to retaining knowledge, recalling concepts and defending my clinical decisions. Be challenged! It makes you better.

So, to all my teachers, peers, students and student-teacher-peers, let’s accept our own weaknesses, drop the sense of vulnerability that we hold dear in our construct of what it means to make a mistake, and learn always. For me, it’s a must, because medicine is way too cool to ignore, and way too important get wrong.

 

Here is How I Pimp: An example.

Please remember, I used to be good at something else [see above image] before I became a doctor, and I taught others how to do it well. I am not trying to be the PGY1 who tells his senior residents and consultants they have it all wrong; this whole pedagogical philosophy I am sharing is probably outdated and unsupported by evidence, and I look forward to developing it further through the mentorship afforded to me at McMaster.

I’m not the best preceptor, but I have about 20 emerg and critical care topics in my head that are my go-to’s. They translate well from paramedicine to medicine, and can be executed at different levels of advancement depending on my audience.

Here’s an example of my sepsis pimping session, which is accompanied by a sketch on a piece of paper that the learner can take home.  I’ve had this conversation with at least 100 learners over the past decade.

• Identify if/what the learner wants to learn

We have a few minutes, would you like to go over any topics?

• Spend a few moments sorting out where the pimpee is at

What can you tell me about sepsis?

• Set up question one for success

Can you think of a few conditions that can lead to sepsis?

• Tell a story as you flow through your pimping questions… lead up to the true message. Foreshadow future questions.

What do all those conditions have in common? *infections

What is the systemic effect of infections on the body? *inflammation

What clinical or lab signs might indicate inflammation?

Now here’s where I get really excited, since I’m a medic! *foreshadow

How does sepsis kill someone? *they got stumped!

• Explore pauses to see if the pause is healthy (is the pimpee trying to recall, do calculus, access memory?) or is the pause unhealthy (is the pimpee anxious, sweating, fidgeting?). Healthy pauses can be prolonged. Unhealthy pauses should prompt redirecting/rewording of the question.
• Have forks in the road you can take if a question is too hard/easy. Apologize/normalize when a question is too hard.

Ok, that’s a broad question, I forgot you were a CC2. *apologize

What’s the difference between sepsis and septic shock?

What clinical or lab findings might lead you to call for help?

• Make it clear you are getting to the whole point of this

Ok, here’s the punchline:

• Do brief teaching. One or two bricks, no more. Use a memory aid.

Septic shock: Think A, B, C!  Antibiotics, Boluses, Constrictors

Septic Shock: Kill a Wet Cat!  Kill the bugs, Fill with fluid, Catecholamines

• Reinforce the point of the lesson. Get the learner to lead this summary.

Septic shock kills people. It’s important to recognize and treat it early.

• Allow for questions in an open, nonthreatening environment.

Sepsis is complicated, and we went through that quickly. Was any of that confusing? Do you have any questions?

• Give homework or resources.

If you have time, see if you can sort out the difference between cold shock and warm shock. It comes up on exams frequently!  There’s a great blog post that explains it.

• Thank and encourage the learner.

Thanks, that was fun! You know your stuff, and you ask great questions. Keep it up! And remember, sepsis is deadly! Kill a Wet Cat!

Total time for me run through this with the average learner: 5 minutes.

How do you pimp? What do you think of my method? How can I improve?  Comment below or on facebook/twitter!  Thanks!