The RITE Stuff

It’s that time of year again, I wanted to share some thoughts on medical pedagogy.

It was recently suggested to me that a series of blog posts on a variety of neurological topics–review review articles written by faculty from various subspecialties–would be helpful to the residents in preparing for the RITE* later this month. My response was that the exercise of writing such articles would be an excellent way for the faculty to consolidate their understanding of the topics, but would do relatively little for the residents’ learning of them.

The principle here is that learning is an active process–it is constructed, to use the academic term. Knowledge is constructed in the process of designing an outline of a neurological topic, fleshing it out with information, re-reading textbook and journal entries to ensure that the information is up-to-date, and polishing the article. Knowledge is even further constructed when others criticize the article, making you re-think or defend your understanding.

Now, I love learning–always have. I could indeed write some stroke reviews and ask our faculty colleagues to do the same within their respective areas of focus. But then we would be the ones constructing knowledge, whereas you would be engaged in the passive exercise of reading, trying to memorize facts and quickly regurgitate them on the RITE. And soon the boards. And soon thereafter any information not in consistent use would be forgotten.

Anecdote: When I was a student at Jefferson Medical College, they used an extremely fact-based and highly competitive pre-clinical format. Each class had a thick syllabus that was essentially read to us bit by bit during each lecture. (You may not be surprised to learn that I never attended lecture). Anyway, we were expected to essentially memorize these syllabi for the quizzes and tests, all of which were multiple choice. My medical fraternity had thousands of pages of “back tests” that we used to work through, trying to figure out why the heck the answer to #211 was “a” and not “c”, and frantically ripping through the syllabi to find the sentence fragment that would substantiate that “a” answer.

So, I’m burning through a tedious immunology syllabus when I encounter a table of CD antigens that takes up the entire page. There must have been 30 antigens with their associated descriptions. I stopped for a moment and, in true utilitarian medical student form, adjudged that the payoff per minute spent was far too small to warrant memorizing that page. I’m pretty sure I actually said out loud, “well, &$@!, if they ask me what CD something-or-other does, then I’ll just surrender that question.” Sure enough, one of the questions on the ensuing test was something like:

CD20 is:
a) B-cell antigen
b) T-cell antigen
c) etc.
D) etc.

I literally laughed out loud during that test. And to this day, I remember that CD20 is a B-cell antigen. Importantly, though, I didn’t then and certainly don’t now know what role it actually plays. And that’s the difference between knowledge and understanding.

So, that’s why our stroke fellow, and not the stroke faculty, is the one giving a mini-lecture at the beginning of each week’s conference. He develops his own knowledge in the process of creating those presentations. We’re there (residents too–not just the faculty) to ensure that the edifice of knowledge he builds is structurally sound. We do that not only by checking his facts, but ideally by asking probing questions.

That’s why Dr. Jensen’s Integrated Neuroscience course for the second year medical students incorporates problem-based learning. Those of you who were small group leaders undoubtedly encountered some initial, perhaps even ongoing, resistance to the unfamiliar format. You may have noticed a strong tendency to focus on getting the “right” answer, even though some questions didn’t even have right answers. This, in my view, is the regrettable consequence of our fact-based (as opposed to understanding-based) and competitive (as opposed to collaborative) approach to medical education. The theory behind the small group sessions is that students will learn neurology better if they think through fairly realistic cases, look up the relevant anatomy and neurology on their own, and discuss and debate the questions among themselves. Our role as small group leaders is not to ensure they end up with the right answer, but to guide them as they develop a (rudimentary) neurological edifice.

And that’s why I suggest that the residents, and not the faculty, write up the proposed series of mini-review articles. One idea is for the group to pick 10 topics about which everyone feels a little weak. Genetics, say, or uncommon causes of stroke, or autoimmune diseases other than MS. Each resident picks the topic he/she feels most uncomfortable with and proceeds to write up a short review and post it here. The residents read all of the posts and use the comment feature to discuss, challenge, and defend the articles. I’ll definitely participate and will try to get the most authoritative faculty to weigh in as well.

All UW residents are all registered as authors on this blog and so can post your own articles. You just need to log in with your last name (link on the right under “Miscellaneous”). Your default passwords are all “neurology”, I think. They might be “Neurology”. I can reset them if needed and you can change your password yourself once you log in (which you should definitely do now that I’ve broadcast them to the whole world 🙂 )

Good luck!

* RITE and Continuum are registered trademarks of the American Academy of Neurology.

About Justin A. Sattin

I'm a vascular neurologist and residency program director. I created this blog in order to share some thoughts with my resident and other colleagues, and to foster my own learning as well.
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