COMMENTARY

Confessions of a 'High-Yield' Doctor

Benjamin Mazer, MD, MBA

Disclosures

November 20, 2019

I was recently reviewing microscopic slides with my attending for a rare form of cancer. I took one look and quickly blurted out the diagnosis. A bit surprised, he asked whether I had seen a case of it before. "Not exactly," I said. "I saw a picture of this once on Twitter." While experiences like this are becoming more common in medicine, it still baffles some physicians that you can learn about rare diseases on social media.

Now in my last year of residency training, I've been thinking about how much digital medical education has evolved just since I started. During my first year of medical school we used microscopes, but by my second they had been replaced by iPads. New online study tools such as Pathoma and SketchyMicro became available, and the official curriculum was shrugged off or even ignored. Essentially all of my classmates used unsanctioned third-party resources like these, while only a fraction would regularly attend our lectures. I didn't even meet a few of my classmates in person until our clerkships began.

I am part of a new generation of doctors, the "high-yield" doctors. And having been molded into this role, I believe that medical education needs to adapt to these changes—in part by returning to its roots.

Rise of the 'High-Yield' Doctor

But to take a step back, what is a high-yield doctor? And how did this become the only way to get through medical training?

Today's medical students, as in past generations, are expected to regurgitate fleeting minutiae. "High-yield" facts are those most rumored to show up on exams and in attending teaching sessions, and electronic studying tools can target these facts with surgical precision. They contain short, informal videos and tidy bullet-pointed text, and they are, to be sure, a compelling product for overextended students.

Most medical students now consider high-yield digital study tools to be the core of their preclinical experience.

These tools have become essential in an arms race over a silly test: USMLE Step 1. Despite being the least clinical of the USMLE exams, it is the most important in resident selection. Any student who wants some say in the course their training will take—meaning every student—cares about their Step 1 score.

A group of medical trainees led by David Chen recently wrote a persuasive editorial against what they call this "Step 1 climate." They argue that the focus on this test has "created a rift in medical education" where students "disengage" from the formal curriculum in favor of studying for the test. This has been a "profoundly negative experience" for students. To this day, I associate the test with months of anxiety and nausea.

Most medical students now consider high-yield tools to be the core of their preclinical experience. Chen and coauthors astutely call commercial Step 1 resources "the de facto national curriculum of preclinical medical education."

The Appeal of 'Raw' Medical Education

The importance of Step 1 performance is not the only driving force, though. The Internet's immediacy, ubiquity, and democracy are influencing medical education as much as exam mania is. A recent New York Times article laid out what the current generation of "digital native" students is after: convenience, interactivity, practicality, and authenticity.

One educator I know who understands this is Dr Jerad Gardner, an associate professor at the University of Arkansas for Medical Sciences. He is one of the most followed pathologists on social media, and his video tutorials have more than half a million views to date—no small feat for a niche specialty. After first experimenting with heavily rehearsed and edited videos, Gardner told me that he now records his videos "raw," mimicking an impromptu teaching session.

This model is a hit with his students and across the globe. "No one really minded that even though I stumbled over my words or I talked kind of fast...people still accepted it even though it was imperfect," he said. "That's the way they're used to taking in their knowledge since childhood, basically."

Much of my training has indeed been informal, absorbed in short bursts during downtime on social media or through pathology quizzes provided by volunteer academics. Even though Step 1 is now years behind me, I still find that the high-yield facts and patterns of pathology fall more easily into place using crowdsourced digital tools.

On-demand learning tools are becoming influential across specialties. The American Board of Internal Medicine, for example, recently institutionalized the high-yield doctor by allowing an online "open book" option for their board recertification exam. The American Board of Anesthesiology is piloting rapid-fire online questions in lieu of lengthy recertification exams.

Medical Schools Tighten Their Grip

Professors acknowledge students' declining engagement with traditional teaching methods. Dr Robert Homer, director of medical studies for the pathology course at Yale, told me he thinks "medical students perceive all preclinical medical education as something to be gotten through as quickly as possible in order to do whatever it is that they really want to do." Medical schools have tried to adapt. They restructure or shorten lectures, adding more interactive sessions. Some schools have even shortened preclinical education. Yale medical students begin their clerkships by their second year of school.

My generation has paid more for medical education than any other but probably uses it the least.

I often feel bad for today's medical educators, who are pushed to cover an ever-widening range of disciplines: epidemiology, economics, nutrition, or even product design. But medical schools have responded defensively, apparently trying to prove their ability to produce and evaluate new doctors by tightening their grip. Byzantine "learning objectives" and "milestones" proliferate. Over the course of my education, I've been handed hundreds of pages of these checklists. I don't know if I've ever read a single one.

It's no new insight that bureaucracy is self-perpetuating, especially when abundant healthcare and tuition dollars are involved. The final irony is that as students organically increase their reliance on unsanctioned extracurricular material, medical education has grown more expensive, bureaucratic, and formally evaluated. My generation has paid more for medical education than any other but probably uses it the least.

The Digital Apprenticeship

Meanwhile, what doctors choose to call "knowledge" is evolving as well. The growth of evidence-based medicine has threatened much of medicine's traditional sources of educational authority. The randomized trial has replaced self-assured textbooks as medicine's most-respected source.

Yet, hard evidence often falls short. In my experience, the result is that medicine's "facts" quickly dissolve into factionalism. Guidelines and experts, some beset by commercial interests, battle for influence in the absence of definitive data. Social media and investigative journalists have put a spotlight on this historically internal fight.

In the midst of all this, high-yield learning is a comfort when medical facts are seemingly open to debate and the volume of available information keeps growing. The high-yield doctor, in his or her worst moments, looks to digestible factoids because they get rewarded—first by multiple-choice tests, then by a defensive, litigious medical system that pounces on deviations from "standard of care."

To truly adapt to an evidence-based medical world, our training models should retreat from the bureaucratization and high-yield demands they've been embracing. Evaluating students through checklists, multiple-choice exams, and other empty metrics allows them to avoid the hard questions doctors face when interpreting evidence.

Instead of simply emphasizing technology's teaching power, let's turn to its communication power. On social media, I talk to fellow trainees as well as experienced attendings in various specialties, not to mention epidemiologists, scientists, journalists, and policymakers. Conversations are informal but educational in a way that can't be captured by rubrics.

This type of learning isn't new. The improvisation and interactivity of apprenticeship-style training has been the real foundation of medical education for more than a century. In the wake of the digital revolution, we can reconsider the value of this model. Maybe a digital apprenticeship is the future of medical education. Preclinical education can spend more time discussing how to search for and interpret online information. Emphasis can be placed on how to reach out to colleagues globally for help. Let's replace a few exams with online journal or book clubs that include doctors, patients, and other stakeholders.

I can't deny it. I'm a high-yield doctor. I can memorize facts as efficiently as ever with the help of digital study aids. But I can also dive more deeply into the evidence underlying our practice, and find diverse voices to debate it with online.

I am a high-yield doctor, which means seeking out understanding everywhere.

Benjamin Mazer, MD, is an anatomic and clinical pathology resident at Yale with interests in diagnostic surgical pathology, laboratory management, and evidence-based medicine.

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