STATE OF HEALTHCARE
Educating in the Era of Information Overload: An Interview with Rick Nishimura, M.D.
Gerik L. Educating in the Era of Information Overload: An Interview with Rick Nishimura, M.D. Methodist DeBakey Cardiovasc J website. journal.houstonmethodist.org. March 26, 2018.
cardiovascular education , medical training , fellowship , residency , clinical decision-making
When it comes to cardiovascular education, Rick Nishimura, M.D., is a leader in his field. In his 38 years of teaching fellows at the Mayo Clinic in Rochester, Minnesota, Nishimura has earned 46 teaching awards from his home institution along with the Laennec Clinician Educator Award from the American Heart Association and the Gifted Teacher Award from the American College of Cardiology (ACC). Today, Nishimura holds the Judd and Mary Morris Leighton Professorship in Cardiovascular Diseases and Hypertension at the Mayo Medical School.
MDCVJ: What makes your teaching style so unique to have earned you so many awards?
RN: I like to use the Socratic method. I will never provide an answer to a clinical question directly, but require the fellows to look up the answer on their own, reflect, and then we’ll have a discussion. I’ve had fellows come back and say they appreciate the education we provided on how to educate themselves.
MDCVJ: What are the biggest changes in educational paradigms since you were a fellow?
RN: These days, medical facts can be looked up instantly on smart phones or other devices, so the knowledge and facts don’t need to be taught or memorized. The major thing that we, as educators, have to do is teach people how to use those facts. It boils down to teaching clinical decision-making, as well as assuring that other competencies are developed, such as compassion, empathy, and talking and listening to the patient.
MDCVJ: How can educators teach clinical decision-making to fellows?
RN: You have to do it through a case-based approach since every patient is different. I use what I refer to as “learning opportunities.” This means teaching during the time that we’re seeing a patient or in the cath lab performing a procedure; the best education occurs at the point of care where the individual patient brings out specific individual questions. The teaching is most effective when addressing these questions that must be answered to provide optimal care to the specific patient. If you’re teaching in a conference, you then bring in those patient cases, present to the audience, and create a cognitive dissonance with questions about what the audience would do at that time. After the audience has had time to outline what they would do, you then take them through the clinical decision-making process.
When I was at the ACC Heart House with Miguel Quiñones and William Zoghbi decades ago, all of our courses consisted of didactic lectures, followed by a select few clinical cases. When we did our needs assessments with feedback from the audience, everyone said they wanted more and more cases. On the basis of this feedback, we started created learning sessions based entirely on cases. These became more and more popular, and soon this type of educational session became state of the art.
MDCVJ: Across cardiovascular education, particularly fellowship programs, what are some of the things we’re doing well and what do we still need to improve?
RN: There are basic core competencies that have been defined for the fellowship program with milestones, and programs are meeting those fairly well—understanding and teaching the basic knowledge and skills required for a competent cardiologist.
However, there are two areas that still need to be explored. Number one is developing the concept of a competency-based curriculum. Although everyone learns at different speeds, we currently have a time-based curriculum, where fellows will spend a specified number of months in a certain clinic or laboratory. What we really need to do is create a competency-based curriculum so that as soon as one achieve a competency in an area, they can move on.
Number two is going back to the clinical decision-making. Because we have all these new imaging tools and catheterization-based procedures, fellows tend to use the results of testing alone to make decisions. True clinical decision-making involves taking a good history, doing a thorough physical examination, and making sure everything you’re doing is concordant with the testing before making a decision. Many times you might find that you have discordant information from your history and physical versus the testing, which tells you that you need more information before making a decision. By having that interaction with the patient, you also learn about the patient’s preferences, which should play a huge role in your final decision; it’s important to use the shared decision-making process rather than the physician dictating to the patient what to do.
MDCVJ: In your Grand Rounds presentation here at Houston Methodist (click to view video), you talked about knowledge overload. Can you describe that and explain how it affects trainees and educators today?
RN: These days, knowledge is being created at an exponential pace. It’s impossible for a physician to maintain all the knowledge necessary to take care of the patient. That’s the knowledge overload. The information overload is the fact that each individual patient has thousands of individual laboratory or procedural results – it is difficult to sort out what information is truly relevant to a particular clinical decision. In the future, we need to use the electronic health records and information technology to help us put those two things together. By using artificial intelligence through machine learning, all the vast patient information will be sifted through and it will only be the pertinent aspects that will be presented to the physician. At the same time, the medical knowledge will be interrogated and the relevant updated clinical knowledge will be presented so that the physician is able to make the right clinical decision for the individual patient.
MDCVJ: Is that sort of AI being built now, to your knowledge?
RN: It is being built and tested and we anxiously await the results.
MDCVJ: The Mayo Clinic has a unique Knowledge Management Program addressing these issues. How does it work and how does it affect Mayo’s physicians?
RN: This comes back to knowledge overload. At Mayo we have experts in every single area. When I began practice 30 years ago, we used to know everyone and know who had what expertise. When we had a question about an area we were unfamiliar with, we would just pick up the phone and call the expert. Now, throughout all our sites, we have thousands of physicians, each of whom has their own expertise, and it’s hard to keep track of who knows what. So we created this Knowledge Management System where the pertinent knowledge is put into bytes of knowledge stored in a content management system. Our experts input their knowledge so that physicians all around Mayo and our subsidiaries can access these bytes of knowledge whenever they need them. Now we are starting to combine that knowledge with individual patient data to present to the physician at the point of care.
MDCVJ: Are there any closing thoughts you’d like to leave with our readers?
RN: Even though there’s all this expectation that the computer will put together the knowledge and the information, the physician still plays a key role in making a clinical decision based on both the knowledge and patient information and the needs of the patient. Different patients will have different needs and expectations. Although it takes a lot of time and effort to sit down with the patient and present all their options, this needs to be done to come to a mutual decision, which we term “shared decision-making.” It’s a terminology which has exploded in the literature, but I think very few physicians know how to do it properly.
That’s going to be the biggest challenge: training young physicians to combine all this specific patient information with the exponential growth of medical knowledge and arrive at shared decision-making process with the patient. Even though the pressures on physicians are increasing, I feel that it’s our responsibility to take the time—even if it means we’re going to be working an hour or two later every night—and make sure we’re teaching these youngsters to do what is best for the care of the patient. That is the reason we all went into medicine in the first place.