Teaching and learning are not two sides of the same coin

Once again, I find myself in a situation where I wish to impart important information that I have garnered over my career, yet there is no way to do this without sounding haughty. To put things into perspective, none of my personal accomplishments over the last 20 years would have been possible, if I’d not met and worked with Dr. David Applebaum. It was his vision that created the concept of pre-hospital care of high enough quality to dramatically reduce the stress on emergency rooms. I should point out that there are official, public statistics from the Israeli health ministry that prove the tremendous positive effect of Dr. Applebaum’s creation. There are no words to express the tremendous loss to the world from his murder, along with his oldest daughter, in a terror attack. All I can do, and all anyone can do, is try to preserve and advance his vision. I hope that my contributions fall into this category.

I just read an article (in the Dec 8th edition of JAMA) related to training physicians to provide high-value care. Without formal intent, it turns out that I created such a teaching environment for all of the doctors I worked with, over the 11-year span that I created and developed my electronic medical record system [EMR]. My former place of employment was an astonishingly effective beta site that was not limited by the bureaucracy and closed-mindedness of most medical institutions.

In the JAMA article, the first component of successfully training physicians is noted to be knowledge transmission. This is a relatively fancy way of saying, teaching doctors in the classic, old, didactic fashion. Whether by lectures or emailed summaries of important medical updates, this type of teaching has been shown to be important for laying a foundation, but fails to create the transformation in the mindset of the student.

As an example of the problem with this approach, one need only ask a physician about topics he or she learned during their basic sciences component of their medical school studies. Unless the physician is a nephrologist, urologist or pharmacologist, he or she is unlikely to remember the key way in which our kidneys save fluids and maintain stability in the levels of key blood components, like sodium and potassium. Admittedly, if the physician needed to know this critical bio mechanism once again, he or she could brush up on the topic relatively quickly. This shows how such classroom teaching forms the foundation of medical education but does not necessarily keep the information top of mind.

In the system I designed, there were multiple components that taught the physicians in a didactic fashion. I created a course called TUCS, which summarized the wide variety of clinical issues  that an urgent care doctor would come across. This was one of the first of its kind, i.e. a course specifically geared towards urgent care, which focused on the critical components of the day to day workflow. In urgent care, a physician will easily find him or herself dealing with a child with fever, a young adult with abdominal pain, and older adult with chest pain and an elderly individual with headaches, all within the span of a single hour. To succeed in such an environment, one needs a foundation that is very protocol driven. Obviously, it is important to understand the entire pathophysiology behind each type of malady. But in practical terms, the physician has to be comfortable (not necessarily expert) with this whole range of clinical topics.

One of the tools I created was actually an award-winning website that presented X-rays along with a short clinical history, which required that the physician not only identify the pathology on the X-ray but also specify how the patient should be managed. This X-ray teaching site was very successful amongst the physicians and definitely contributed to their skill with reading X-rays and treating the associated problems.

The second component to training physicians effectively is referred to as reflective practice. This refers to providing feedback to physicians about their performance, in a constructive criticism format. During the course of their training, physicians are yelled at enough by their seniors. The key is to get physicians to see teaching as a positive influence, rather than a way to embarrass them. I created a system that allowed me to review high-risk cases, almost immediately after the patient’s discharge.

My EMR automatically identified these cases by virtue of a whole range of clinical features. For example, if an older patient presented with a cough, but then went on to be tested for chest pain out of concern for an MI, my system would identify this as a high-risk case and flag it for review. Contrarily, the case of a sprained ankle where the X-ray performed confirmed that there was no fracture, tended not to be secondarily reviewed. I should point out though that another component of my EMR allowed for radiologists to review every X-ray done throughout all of the clinics and to flag any case that seemed suspicious, for any reason.

The likelihood of the entire clinical system missing an important finding on an X-ray and also not reporting an important finding to the patient, was nearly 0. Considering that in the later years, my former place of employment was assessing over half a million patients a year, an error in less than a handful of patients per year is as close to perfection as humans can hope for.

The system was very effective as it provided feedback to the physicians within 24 hours after the patient had left. In many other institutions, chart review and feedback can easily occur weeks to months after the patient was treated. The physician has no recollection of the case by this point and as such, the information being reviewed is equivalent to a case study, which falls back under the first category. On the other hand, if a physician, for example, failed to check for an important clinical entity, and that physician is told of this only a few hours after the patient has left, this has a very strong impact on the physician and can truly change behavior in a positive way.

Another component I designed allowed for near real time feedback on certain critical clinical issues. This means that even before the patient left the clinic, the physician already received feedback on the care. Time and time again, I personally witnessed young physicians blossom under this system. Based on their own reviews, I was told multiple times that their time in the clinical environment I created, prepared them for their future training in an excellent fashion. Needless to say, I’m incredibly proud of that fact.

The third component is referred to as a supportive environment. One of the classic problems that every young physician deals with is the lack of a mentor or senior physician to consult with 24/7. Every doctor remembers being up at 3 AM with a patient who is not doing well. The same doctor also very well remembers the anxiety and pure fear of calling the senior at home, waking him up and then being yelled at, even if the phone call was totally justified. I know of one truly goodhearted resident who told me how after being on call for 30 straight hours, he dared to call his senior who actually just hanged up the phone. In the morning, though, the same senior lashed into this resident for doing substandard work. If this sounds insane, you are right. I would ask you to read my previous blog post to become even more disheartened with the way physicians behave.

During my tenure as a senior medical consultant, I had one clear rule that I shared with both the doctors and nurses, and even the X-ray technicians and secretaries. I told them all that the only reason I would ever get angry was if I was NOT called when there was a clear need for it. For over 10 years, I rarely got through the night without a phone call from one of the staff from one of the clinics. Usually, the staff member would apologize for calling me in the middle of the night. And I would reflexively respond that there is absolutely no need to apologize and that I thank them tremendously for caring enough to make the call. Sometimes, I needed to spend a good half-hour dealing with the case, reviewing the X-ray or ECG, looking at a photograph of the injury  [via another part of the system I designed] and then finally coming to a conclusion with the physician on site. As I ended the conversation, I would once again thank the on-site physician for caring enough to make the call.

It was known in my former place of employment that I was always available for any problem. I even once dealt with a case being handled by a young physician who, on that night, was working for another company. I asked him if he didn’t have a senior to consult with, and he told me that the senior was not answering his phone. I was proud of the fact that this young doctor felt comfortable enough to call me, because it was truly his desire to help the patient, independent of any other factor.

I could not have done all of these things if I had not been working in an environment that allowed me to create, without limitation. Also, it should be clear that without open-source software and cutting-edge hardware, I could not have done all that I described above. For example, I was possibly the first physician to regularly provide consultations on X-rays and ECGs via smart phone. I was one of the first people in Israel to purchase a smart phone with a sufficiently large and high quality screen that allowed me to read the X-rays.

A formal consulting system that I designed captured all of the clinical information about the patient and presented it automatically to the remote consultant. All of the information about the patient and the response of the consultant was contained within the computer system, and held to HIPAA standards, even though this standard was not required in Israel.

I should point out that I had the tremendous fortune of working with a gentleman by the name of Yossi Odenberg, who constantly worked to find the best but least expensive, hardware solution for everything I asked. He is as much of the reason for my success with my EMR as anyone else. I also had the tremendous luck of working with a young, brilliant woman who designed a great deal of the web-based components of my EMR. My experience demonstrated to me that a very small team, dedicated to a common and important cause, could do astonishing work. To replicate such an amazing work environment would be very difficult, if not impossible. I was lucky enough to experience it once.

In summary, I can personally attest to the fact that the JAMA article I referred to above is accurate, simply because I have had success with all that it describes, beginning over a decade ago. I hope that more and more people embrace this type of physician training. Anyone who would wish to discuss it with me in more detail is welcome to contact me via my email.

There are many doctors who have the best intentions when they start their training. But many of these doctors get beaten down by a system that (a) is not focused first and foremost on the welfare of the patient, and just as important, (b) does not create a positive mindset in the physicians. I believe it is definitely possible to create a positive learning environment for all doctors. It takes work. But, it’s a general principle that anything worthwhile in life, takes work. And what is more worthwhile than providing the best possible health care to people in need?

Thanks for listening.

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.