In Part I of a new series, Drs. Greg Henry and Mel Herbert discuss the role of technology in medical education
EPM: How have you seen the use of technology in medical education change over the course of your careers? What have been your observations?
Greg: Having seen education change with a lot of gizmos, whistles and buttons over the last few years, there are few things that I would like to point out. First, all change is not progress. Second, everything is secondary to a great live lecturer. No matter how good the presentation is, when it comes off on a 12x16 inch screen it's not necessarily keeping your attention the same way that a live body does. There's a reason why live theater and rock concerts thrive in the face of the ability to broadcast on television and pump music into your iPod. The reason why this works in education is that there's an epinephrine outflow that makes things stick if the presentation is live in front of you. Since the invention of the printing press, since Gutenberg, the question of the lecture has been in doubt because everything could be printed and mailed out. But in the end, everything that we have come up with in education is adjunct to the great lecturers.
Mel: We’re really talking about the two basic forms of emergency medicine education. There is the hands-on, like knowing how to do a chest tube or airway. You can lecture about these all day, but in the end you just have to learn the motor skills. Then there is the purely didactic education that needs to take place. There are a certain number of facts and figures and associations you need to learn, a mass of information that you need to shove into your head. It’s a hell of a lot of information. I'm not old like Greg. I'm only 47 and Greg is, I think, 1,047. I can only talk about medical education from the early 80s to now. And although I agree with Greg that a great lecturer is the beginning of all things, I don’t think it's the end of all things. When I came to the United States in 1991, I walked into a room where Jerry Hoffman was giving a lecture and I was frankly astonished at how good a speaker could be. I'd never seen that before in Australia.
Greg: That’s until you heard me, Mel.
Mel: And then I realized that he was the second best speaker in all of emergency medicine. He was just so good at that Socratic method of posing a question and getting feedback and being able to reference the world of literature from his brain without having to flip through a textbook. It was a revelation to me that teaching could be that good. Like many others, I’d grown used to the typical medical school teachers – researchers and the like who are simply told to teach. Frankly, most of them suck; they're uninteresting and disorganized. Seeing great speakers like Jerry Hoffman and Greg Henry makes you realize how good it can be. My feeling is that we can enhance that experience through the use of technology. It's not good enough to have great live conferences because you can't get Greg and Jerry and Rick Bukata and guys like this spread throughout the emergency medicine universe by doing it 200 or 300 people at a time. My advice is that we have to capture the lectures of these high-caliber teachers so that we can then disseminate it to more people. The live course might be good – and very powerful – but it has to be disseminated beyond that audience.
The second point is to look at what's happening with groups like the Khan Academy. The idea of turning the classroom on its head. Right now the traditional thing if you go to an EM residency or you go to a third-rate classroom, the teacher gets up there and lectures for an hour and then you do some questions and then you go on to the next topic. What the Khan Academy (funded by the Gates Foundation) has said is, “Why don’t the kids at home learn at their own pace, a segment of information,” – let's say it's how to diagnose and MI – “and then when we go to the classroom, instead of just lecturing at you, let's discuss the material that you’ve already listened to. This turns the classroom time into a question and answer, which is where people learn at a much higher rate than just listening. That’s where I think we’re heading, and it's really happening through places like the Gates Foundation. You're going to see it in schools, and medicine will follow because we’re always behind in everything. But that is a much more efficient way to do it. “Here is Greg’s great lecture. Now we’re going to discuss Greg's great lecture when we get together as a group because we can't get Greg in the room.”
Greg: Mel has a lot of very good points here. The first one is, “Why reinvent the wheel when there's been a brilliant talk on X, Y or Z.” And Mel and I could probably sit down and come up with the 50 touring pros in emergency medicine who you go to hear just because it's so much fun to go hear them. When they've already done a great job, why should somebody reproduce that at each and every residency? Here's the problem. We need to turn out more great teachers, and it is my belief that every doctor is a teacher, if only by bad example. We need to take those people coming up through the residencies, and the faculty at the residencies, and make them great presenters. I realize they all can't be Jerry Hoffman. But they can all be passable. And I think you need to have some of those skills even to run the question and answer sessions for these folks. I will be doing a series of workshops for the American College in Dallas, Texas. We are going to have that interactive base, but at some point in time you have to come together with another human just to keep your interest and emotion level up. The thought that somebody is going to call on you, and you're going to be asked to rise to your feet and speak live in front of other people, I think is a useful learning technique. I know we can't do it in every situation, but I rue the day when we don’t think that that has an importance in bringing out better doctors.
EPM: Mel, do you think we’re dumbing down our teachers?
Mel: No, I don’t think so. I think we’re actually making them better. And I say that because I see the quality of lectures given get better and better. It’s because we are exposed to the internet and we can listen to other people's lectures and we can steal from them. When I saw Jerry Hoffman lecture and I was just stunned at how good they were, I just stole his lectures. He gave a great lecture on arrhythmias. I stole that lecture, made it my own, and I frankly made it better. Since then people have stolen that lecture from me and made it even better. There is something very useful about disseminating this stuff and having people appropriately steal your ideas and improve on them. Again, it's about dissemination of information. If we can disseminate the best lecturers, the best talks throughout emergency medicine, rather than just sort of hit and miss, then I think people get exposed to the right way to do it. And I think you have to have both, like Greg said. There's nothing I find more useful than sitting through a really shitty lecture, because then I go “Oh now I remember why I hate bad lectures.” But if I get to hear Cory Slovis lecture on electrolytes, I’m done. That’s the best lecture on electrolytes that I've ever heard, and now I can improve on that. I think that seeing and hearing and listening to the great speakers can make you a better lecturer than just sort of fumbling through it yourself. It's OK to steal the concepts and the cadence and the way of speaking from a great speaker and then make it your own. And the only way to do that is for you to get exposed to them and the only way to get exposed to them is if you can hear them live. But the problem is that if you don’t register for one of Greg Henry’s talks at ACEP in the first five minutes, it's sold out. You can't see it. And maybe you go to ACEP every five years. Maybe you're one of those people who only hear Greg a few times in his career. But if there's a recorded Greg Henry and, even better, a video recording of Greg Henry, everybody can see it and learn from it. But I do agree, you have to practice it. That is an issue that I'm dealing with trying to develop a sort of farm team for faculty members so that they can learn those basic skills as well. But I don’t think doing a bad job over and over again and not being exposed to great speakers is the best way to do it. You have to watch the best and sort of mimic the best, and then practice. But first of all you have to see how the good people do it.
Greg Henry, MD is founder and CEO of Medical Practice Risk Assessment, Inc.; past president of ACEP.
Mel Herbert, MD is founder of EM:RAP and the chairman of Essentials of Emergency Medicine