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The Evolution of Medical Education

by Monte Troutman, DO – Publications Committee

This piece was originally published in the January/February issue of the Tarrant County Physician. You can read find the full magazine here.

I can brag on myself as I have been involved with medical education for over 40 years now. Thirty-seven of those years were spent working as an assistant and then an associate professor of medicine at the Texas College of Osteopathic Medicine (TCOM) within the University of North Texas Health Science Center. I was the first full-time gastroenterologist there. I left private practice in Dayton, Ohio, where I was adjunct faculty at the Ohio University College of Osteopathic Medicine. I wanted to be more involved in medical education than that position offered. So why am I telling you all this? So you know that I have been around a long time and have seen a lot of changes, including monumental ones in medical education, from the classroom to clinical bedside clerkships. 

UNTHSC developed an Academy of Medical Educators where physicians, other health care providers, and basic scientists at TCOM have learned and discussed the theories and principles of medical education including Bloom’s educational approach and Miller’s framework for assessing clinical competence. 

After we learned the fundamentals, we now concentrate on other aspects of medical education. One of the of most significant changes that has transformed how we educate is that we no longer “lecture.” Indeed, it is now considered a four-letter word—lecturing is seen as passive learning.  Also gone are reading assignments from textbooks. Other forms of education now rule the roost. This includes online education and interactive forms of learning. 

So, what is so wrong with textbooks? About 10 years ago, I read a letter to the editor in the New England Journal of Medicine, where two second-year UCLA medical students calculated the total number of pages assigned by instructors for one semester. A staggering 10,000 pages were assigned and were fair game when testing occurred at the end of the semester. Too much? Yes!

A recent Google search stated the doubling of medical technology in 1950 was 50 years, in 1980 seven years, in 2010 three and a half years, and in 2019 one and a half years. Now in 2020 it is 73 days; not even three months. I recently told this to a fourth-year medical student on my service and as his eyes widened, he exclaimed, “That’s scary!” So, to revisit what is wrong with textbooks, here it is: The editors work with other experts to write a designated chapter, all work is edited and corrected, it is then published, printed, distributed, and purchased, etc., etc. This whole process takes years. So how many times has medical technology doubled in that time frame? Educators still refer to textbooks, but as references, not as primary education material.

A man walks into a bar in New Orleans and asks for a Corona and three hurricanes. The bartender hands him the bill—$20.20. Yes, the COVID-19 pandemic has changed things, possibly permanently. Virtual medical education is the current modus operandi. Zoom, WebEx, Skype, and Join.me, to name a few, are the classrooms today.  Right now, learning clinical skills is generally virtual. Inconceivable but true—not hands on but virtual patients. Not entirely new, just brought to the forefront due to the pandemic.     

Over the past several years, the lecture (that four-letter word again) hall has been sparsely filled unless attendance is mandatory, as some medical schools still do require, or if an in-person quiz is on the schedule. Before attendance began to drop, medical educators made the classroom an interactive session and the iClicker was used to respond to questions. However, with Power Point presentations now online before the lecture is given, and voice over with the Power Point, why go to the lecture hall? Pull up the Power Point whenever you want, play it at 1.5 to 1.8 speed, and listen to it twice. The thought is that the classroom is wasted time, and you avoid being called on in class. 

There is still in-person training. I teach in the second year, which includes small group sessions called Clinical Reasoning Modules (CRMs). In the CRMs, about eight to 10 students are presented with clinical cases by a moderator who leads the discussion on history, physical, labs, imaging, etc. The model used is a version of clinical reasoning called a “mind map,” and it stresses differentials and necessary testing and imaging. Grading is based on participation. As the “clinical expert,” I rotate to all the small groups and answer questions.  This is where I get to meet students I have never seen before. 

So, if there are no textbooks or lectures, what do the students do to prepare or to learn? Good question! Instead of scheduled lecture time, regular time is scheduled during their day to “study.” Faculty prepares Directed Student Activities (DSAs).  The DSAs include society guidelines, videos, online sites like Up To Date and more. Here textbooks are listed, usually as reference rather than test material. As you can imagine, the students are very resourceful and tell me about sites they find on their own that support their learning process.  The list I have been informed about and use to refine my DSAs are Baby Robbins, Pathoma, First Aide, Sketchy Medicine, Get Body Smart, Picnomics, and Hardin MD. As you can imagine, the time spent by faculty to screen all these sites is overwhelming. Since our curriculum is problem-based, symptoms or problems are the topics of our DSAs. Since I am a gastroenterologist, my topics are abnormal liver chemistries (not called LFTs anymore), nausea and vomiting, dysphagia, GI bleeding, constipation, diarrhea, and so forth.  Can you imagine the time needed to condense these topics into DSAs that are current and learnable using this format?

 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. 

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.

Tarrant County COVID-19 Activity – 03/02/21


COVID-19 Positive cases: 243,067

COVID-19 related deaths: 2897

Recovered COVID-19 cases: 225,301

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Tuesday, March 2, 2021. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

Tarrant County COVID-19 Activity – 02/27/21

COVID-19 Positive cases: 241,005

COVID-19 related deaths: 2841

Recovered COVID-19 cases: 220,726*

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Saturday, February 27, 2021. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

Tarrant County COVID-19 Activity – 02/25/21


COVID-19 Positive cases: 240,416

COVID-19 related deaths: 2818

Recovered COVID-19 cases: 219,208*

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Thursday, February 25, 2021. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

Physicians, Stand Together Against House Bill 2029

Advanced practice registered nurses (APRNs) are asking legislators for full practice authority that would allow for essentially independent diagnosis and prescribing without any collaboration with a licensed physician

Rep. Stephanie Klick (R-Fort Worth) filed House Bill 2029, which if passed will allow APRNs to: independently prescribe dangerous drugs and controlled substances (up to Schedule III with some Schedule II privileges in inpatient facilities and hospice); order and interpret diagnostic testing; and prescribe DME and devices – all without any relationship with a physician. The bill is expected to be referred to the House Public Health Committee which is Chaired by Representative Klick. We need every Texas physician’s voice to help us.

Please contact your state lawmakers today. Let them know why it’s important to support physician-led, team-based care. Texas patients deserve the highest quality health care possible. 

Tell them how much you learned in your years of medical school, residency, and beyond. Let them know you are calling on behalf of the patients of Texas, and how your education is much different from that of APRNs and other nonphysicians. Ask them to say “No” to the APRNs and HB 2029, and to help the Texas Medical Association advocate for what is best for patients: a physician-led, team-based care model.

You can use the new TMA Grassroots Action Center to share that message quickly and easily with your representatives.

Virtually Interviewing in the Midst of a Pandemic

by David Lam, OMS-IV

This piece was originally published in the January/February issue of the Tarrant County Physician. You can read find the full magazine here.


The residency application process has changed significantly over the past several decades. I remember a grey-haired attending telling me that when he applied to residency, it consisted of hopping in a car, driving down the freeway, and requesting meetings at hospitals he encountered along the way. A strong handshake later, and the promise of training in the specialty of his choice was secured. Since then, the Match process has been transformed with the stratification of candidates by board examinations which dictate competitiveness for certain specialties. We are under pressure to shine starting on day one, with no assurance that our labors will be rewarded by placement into a residency program.

The class before mine underwent the pomp and circumstance of their Match days at home, sidelined by the COVID-19 pandemic. My class is interviewing for residencies through virtual platforms. We do our best to capture the vibe of a program through an online tour of a hospital recorded on a GoPro camera attached to a resident’s forehead. Our webcams are always on, and we exercise our zygomatic muscles to maintain a soft smile throughout the events of the day. We try our hardest to convey ourselves in the best light possible, both figuratively and literally (many of us have invested in elaborate lighting set-ups). 

This is not an indictment of the residency programs whose attention we are vying for. These are unique times, and residencies face similar obstacles to those encountered by the applicants being interviewed. As we evaluate a place we may call home for the next three to six years, residency programs are navigating how to choose a class of interns without meeting them in person. Then there is the additional challenge of representing the program’s values and culture on a screen. Many have attempted to replicate pre-interview dinners with meal delivery gift cards or virtual resident speed-dating. One residency even sent a care package with personalized memorabilia from their city. 

Although we have lost the ability to explore our future landing spots during the “golden year” of medical school, there are still many silver linings to consider. Instead of having to coordinate plane rides and lodging, applicants can interview from coast to coast in the comfort of a home setting. For students under financial strain, there are fewer restraints on our ability to consider programs that are farther away. Then there’s the benefit that few will admit—wearing shorts or yoga pants out of view of the camera frame during your interview. 

While this certainly is not how I dreamed my fourth year would go, I nevertheless feel grateful. Leaders in graduate medical education are creatively finding ways to help us make informed decisions about the next step of our training. As we interview with leaders in our respective specialties, we reflect on the rollercoaster journey of medical school and the plethora of lessons learned. In the process of making our rank list, we ask ourselves hard questions about what our priorities are. How do we envision our professional identities and who are the people we want to be around during the formative years of residency training? I look forward to the day when I can be the grey-haired attending who wistfully shares stories of virtually interviewing in the midst of a global pandemic. 

Get your Flu Vaccine

by Catherine Colquitt, MD

This piece was originally published in the January/February issue of the Tarrant County Physician. You can read find the full magazine here.

In the midst of the worst pandemic in over a hundred years, it’s easy to overlook vaccine-preventable seasonal influenza. 

According to the Centers for Disease Control and Prevention, as of December 28, 2020, COVID-19 has already accounted for 336,761 deaths and 19,297,396 cases in the U.S. since its first appearance in early 2020. Tarrant County has reported more than 135,793 confirmed cases (TCPH data) and 1,425 deaths so far (https://covid.cdc.gov.covid-data-tracker). The current percent positivity (percent positive tests/all tests performed) for Tarrant County is a staggering 17 percent (also from CDC COVID Data Tracker).1 

For reference, the 1918 influenza pandemic is reported to have killed 21,000,000 people including 549,000 Americans.2

Our most recent prior pandemic, the influenza experience between April 2009 and April 2010, H1N1pdm09, accounted for 60.8 million U.S. cases, 274,304 hospitalizations, and 12,469 U.S. deaths. H1N1 continues to circulate and is still included in the seasonal flu vaccine. A monovalent vaccination produced in response to the H1N1pdm09 pandemic after this strain emerged in 4/2009 wasn’t distributed widely until 11/2009.3

H1N1pdm09 was unique in causing more severe outcomes in younger persons. Approximately 30 percent of persons over 60 in 2009 were thought to have some immunity to H1N1pdm09 conferred by exposure in the past to another H1N1 strain. 

As we make our way through the 2020-2021 flu season while in the throes of the highly politicized COVID-19 pandemic, how will we fare at vaccinating Americans against seasonal flu, and will flu vaccination rates provide some hint at public acceptance of, or enthusiasm for, COVID-19 vaccines? 

According the CDC’s FluVaxView, during the 2019-2020 flu season, 80.6 percent of healthcare personnel received flu vaccines, with 94.4 percent vaccination in healthcare settings which required it and 69.6 percent in healthcare settings which did not make it mandatory.4

In the U.S., for the 2019-2020 flu season, CDC Influenza data are still preliminary but provide a range in numbers of influenza cases from 39,000,000 to 56,000,000, flu medical visits from 18,000,000 to 26,000,000, flu hospitalizations from 410,000 to 740,000, and flu deaths from 24,000 to 62,000. Even using the highest estimate for flu deaths from last season, COVID-19 deaths have already quadrupled the total number of flu deaths last season (https://www.cdc.gov/flu/about/burden/past-seasons.html).5

However, according to Flu Surv-NET (the Influenza Hospitalization Surveillance Network), the number of influenza-associated hospitalizations from 10/01/2020 to 12/05/2020 only totals 61 in the U.S. thus far (compared with prior seasons this is an unseasonably low number).  There is not yet efficacy data for the 2020-2021 seasonal influenza vaccine because of low case counts so far, but most influenza experts expect a mild flu season due to COVID-19 practices of masking, social distancing, hand sanitization, and cough and sneeze hygiene.

As communities struggle to control the catastrophic consequences of COVID-19, getting our flu vaccines and encouraging all of our eligible patients to do the same demonstrates leadership and concern for the most vulnerable among those we serve. Discussing the flu vaccine with our patients also offers context for discussing the COVID-19 vaccines. 

References

1 https://covid.cdc.gov.covid-data-tracker.

2 Epidemiology and Prevention of Vaccine-Preventable Diseases,
13th Edition, p 187

3 https://www.cdc.gov/flu/pandemic-resources/2009-h1n1- pandemic.html

4 https://www.cdc.gov/flu/fluvaxview/hcp- coverage_1920estimates.html.

5 https://www.cdc.gov/flu/about/burden/past-seasons.html

Water Resources in Tarrant County

For residents in West Fort Worth are still affected by boil water notices, as well as others who might be experiencing water shutoffs because of water main breaks and repairs, here is some information about water resources in Tarrant County.

The below locations and times are for Monday.  Be aware that water may run out before closing time.

All locations will have bottled water as well as water to fill containers.

They include four locations that will operate hand out water from 11 a.m. to 6 p.m.

Those locations include:

  • Beth Eden Baptist Church, 3208 Wilbarger St., 76119
  • RD Evans Community Center, 3242 Lackland Road, 76116.
  • Iglesia Templo Jeruselen, 2421 NW 18th St., 76106.
  • Sycamore Community Center, 2525 E. Rosedale St., 76105.

 Open from 8 a.m. to 6 p.m. is Birchman Baptist Church, 9100 N. Normandale St., 76116. 

Disclaimer: Water is being provided to you by the City of Fort Worth in a disaster-recovery situation. It is the responsibility of the individual to ensure that containers being used for water collection are clean, free of contaminates and are a proper water storage container. The City of Fort Worth will not inspect the containers and will not accept responsibility for illness or other any damages that occurs from the service.


 In addition to the city-operated sites, some breweries are offering water to residents.  Please call to confirm hours. 

  • CowTown Brewery, 1301 E Belknap St., (817) 489-5800
  • Panther Island Brewing, 501 N Main St., (817) 882-8121
  • Hop Fusion Ale Works, 200 E Broadway Ave., (682) 841-1721
  • Wild Acre Brewing, 1734 E El Paso St., (817) 882-9453

Resident need to bring their own containers for all breweries.


The Water Department realizes many affected customers have no water to boil and others have no power to boil the water. They are working to secure additional water for distribution as quickly as possible. Additional locations will be added. Continue to check the city’s website for updates. You can also call 817-392-1234 for additional water distribution locations; because supplies are limited, each household is limited to one case.

Tarrant County COVID-19 Activity – 02/08/21

COVID-19 Positive cases: 230,088

COVID-19 related deaths: 2473

Recovered COVID-19 cases: 189,861

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Monday, February 8, 2021. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

Tarrant County COVID-19 Activity – 01/28/21

COVID-19 Positive cases: 213,611

COVID-19 related deaths: 2123

Recovered COVID-19 cases: 161,348

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Thursday, January 28, 2021. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.