e-learning

The Days of the Blue Pages

This week, the second-year medical students in my tutorial group were supposed to diagnose a patient with an acoustic neuroma. Not a real patient of course, but a carefully constructed fictional patient with the typical presentation and uncomplicated history never seen except in cases designed for training junior medical students. On Tuesday evening, the students should have completed the readings in their textbook necessary to answer the guiding questions generated during the Monday afternoon tutorial session. They would have come up with the correct diagnosis by Wednesday, if everything had gone according to schedule.

Each new Brain and Behaviour case begins on Monday, and the first pages of case material are ceremoniously passed around the circle of eight students seated at the table. The first is simply a title page. The title page is followed by the blank piece of blue paper that separates each set of pages from the next; a thin, azure line that recurs in regular intervals throughout the package containing eight copies of the patient with the acoustic neuroma. Each year, there is inevitably one student, usually female, who collects these blue sheets for some obscure purpose, setting them carefully aside.

As the tutor, it is my job to dole the patient out in discrete parts, like courses in a meal: after the title page, then the history of presenting illness (HPI). The HPI must be well chewed and digested before they can have the physical examination (and its blue in-between paper). Some groups are able to serve themselves – is this an acute or slow onset, how fast is the progression, does this sound like a neoplastic process or a vascular one? Other times I cut their food for them, even though I know I’m not supposed to do this. As the facilitator, I am the ‘guide on the side’ not the ‘sage on the stage.’ The point of the problem-based learning format is to help the students learn to think in a clinical fashion rather than absorbing facts in lectures that may not seem connected to human beings in any discernible manner.

I tell my students that they need not just to reach the right conclusion, but to know how they did so. They’re supposed to be learning to think like doctors.

Usually the first three pages of the case are enough for one day. The third blue page is like the period at the end of a sentence spoken by someone who has said enough. The students are supposed to go home with questions and speculations. Then they are to look through the books we told them to buy and come back on Wednesday with ideas, theories, and perhaps, a diagnosis.

When I started tutoring the Brain and Behaviour unit seven years ago, that was more or less how it worked.

This week, we have barely passed the second pages around the table before one student, typing thoughtfully on his Blackberry, comments, “I wonder if this could be an acoustic neuroma.”

Immediately, the three students in the group with laptops (logged on to the wireless internet available in the new tutorial rooms) begin to type. “How do you spell that?” his friend asks.

“Here it is on Wikipedia,” says another. “Acoustic neuroma. Sensorineural hearing loss, vertigo, tinnitus. Involvement of the nearby facial nerve can lead to ipsilateral facial weakness. May lead to increased intracranial pressure, with associated symptoms such as headache.”

Around the table, those without computers nod in agreement or make notes. “So, can we go home now?” asks one of the young women.

I look down at the remaining sheets of paper in front of me: the physical examination, laboratory and diagnostic imaging reports, course and treatment, each section separated by a line of blue so thin it can barely be seen. The students have skipped over several courses of dinner, and greedily downed their dessert before I could stop them.

When this course was designed, students did not bring computers to tutorial with them. They found information in their textbooks, or sometimes in journal articles. They went home and thought about a case, read up on the anatomy and physiology, and tried to connect these to the clinical symptoms of the patient.

Now students type symptoms – hearing loss, tinnitus, facial paralysis and headache – into the search engine of their choice, and almost instantly are presented with the diagnosis. What happens next? I am trying to figure that out. So, can we go home now?

I will say, as physicians have said since the time of Hippocrates, that things were different in my day. When I started working on the wards as a clerk, I carried two books in the pocket of my white coat. One was a small clinical handbook with step-by-step instructions on how to approach everything from chest pain to decreased urine output. The other was a little black notebook that I bought, with lined pages. As clerkship progressed, I would write down the folk wisdom of the housestaff on each service as I rotated through.

The only thing I can recall is that I had dutifully recorded that chlorpromazine was useful for hiccups. Now Google can provide me with 237,000 results for ‘chlorpromazine, hiccups’ in 0.36 seconds. I’d have to be an intractable Luddite not to recognize that the students’ Blackberries are far superior to the little black book of my clerkship days.

Instead of tossing the papers in the air and dismissing tutorial early, I make some grumpy comment about how I had to actually learn this stuff when I was a medical student. We go back over the case and discuss why exactly an acoustic neuroma would cause the symptoms as described. I try to get them to think, to analyze, to be curious, just as they were supposed to back before the electronic world provided them with an auxiliary brain that already knows everything about medicine long before they do.

On days like this, I think of all the other ways we could cover this material. Integrated e-learning options have the potential to completely transform the way we teach this and other courses. We could create cases using video and simulation that would bypass the papers altogether, cases that would be more complex. This might require the students to actually listen to and comprehend what the patient says, instead of picking out key words from a page and searching them on the internet. We could use on-line forums where the students would post their own research so I could see who is actually finding this information and who is passively absorbing it from the group discussion. We could create scenarios where they have to manage the simulated on-line patient, request particular test results in order to receive them, and interpret imaging studies. The horizons are very broad.

Perhaps the way we teach would eventually catch up with the way the students are already opting to learn.

I know there would be resistance, and hurdles to overcome. My own efforts at using technology to implement on-line tutorials for the psychiatry clinical skills training has led to one headache after another. The operating system is too inflexible. I don’t know enough about how these things work to get it running without some help, and nobody seems to be willing/able to assist me. I have to see patients, and I don’t have time to try and learn this stuff. And I’m actually keen to do this, as opposed to most of the academic physicians who probably haven’t given this much thought at all. I can just imagine the looks of horror I would get from all corners of the hospital and the medical school if I suggested we scrap the Brain and Behaviour tutorials and start again with e-learning cases.

Tutorial ends early, as has been the case over most of the term. I slip an elastic band around the remaining pages, which I will save until Wednesday. But I wonder how many more years I will be doing this. Not too many, I hope. In future, the conversation won’t unfold according to the itinerary of those who would control the way knowledge is transferred. Like it or not, students are not going to go back to the old way of doing things, any more than patients are about to stop using the internet to research their illnesses. The days of the blue pages are numbered.