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After the Match

After the Match: Why is Medical Education So Bad?

Cook, Thomas MD

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doi: 10.1097/01.EEM.0000446053.96618.10

    Every year a group of my residents will ask for more “basic emergency medicine” topics at our weekly conferences. I currently budget 200 hours of conference time each year. Seventy percent minimum attendance is required, so each resident sits through roughly 400 hours of conference during a three-year residency.

    It sounds like a lot, and half the time they are sleep-deprived while trying to listen to hour-long “Death by PowerPoint” lectures. We attempt to schedule as many interactive educational experiences as possible including simulation sessions, oral boards, M&M, mock malpractice trials, and topics that revolve around case presentations.

    But I understand why residents ask for the basics. They have spent their entire academic lives trying to figure out this one thing: “What's on the test?” All of their success, in fact, has been based on test performance, and they will have to take more tests to become board certified.

    But is this the best way to learn to help patients? The obvious answer is “no.” True learning is linked to experience. If you do not treat enough folks with STEMIs, you will not become competent no matter how many times you go over ECGs in conference. You need to learn the facts of treating ischemic heart disease, but does that really require hours upon hours of sitting in lectures or reading textbooks?

    Let's consider how post-high school education might function in the future. One theory is that university education, as we know it, will cease to exist. The elite universities will survive as country clubs for well-to-do kids who need a place to grow up. Most of the other schools will fade away after decades of jacking up the price because they thought it was really important to provide overindulged high school graduates with plush housing, gourmet cafeterias, and big-time college sports. But parents footing the bill (the Bank of Mom and Dad) at some point realize that most of what their kids need to know to make a living does not necessitate the extravagance that colleges think is required to attract students and pay for all those brainy faculty members. (

    Wait, you say, this is crazy! How will anyone learn what he needs to succeed in life? Education is the greatest investment a person can make in himself! Make no mistake: education is a great investment, but the way we are going about — from grade school to grad school — isn't working.

    My brother-in-law is a sociology professor at a prestigious southeastern university. He enlightened me about what is wrong with how teachers teach. They become teachers because they actually like listening to lectures, even those one-hour snore-fests that drop your GCS into single digits and induce drooling. What teachers do not understand is that they are the proverbial “one percent” of the education world. This is not the best way to learn for the other 99 percent in the classroom.

    A person on average can only learn three new concepts in a given lecture, and it does not take an hour to learn them. All the talking actually makes it tough for the audience to focus on the most important items the speaker really wants them to learn. And it becomes a colossal waste of time for relatively little return if you throw in the logistics of driving to and from the lecture location. What's the solution? Here are some suggestions.

    TED Talks ( is a collection of online lectures on nearly everything. The reason people everywhere routinely log on and listen is the time limit. Each speaker only gets 18 minutes. That's it, even if the speaker won the Nobel Prize. Make your point and move on. Guess what? People actually learn much more efficiently and enjoy it. In fact, they keep coming back for more. Another major selling point is that the material can be accessed 24/7. No logistical planning or resources involved. The concept has exploded across multiple industries, including the upcoming SAEM meeting in May.

    Khan Academy ( is a start-up made possible by Bill Gates' daughter. Salman Khan, a Wall Street hedge fund manager, produced a series of 10-minute videos on math for his niece. He used Yahoo's Doodle Notepad and uploads them to YouTube. Bill Gates' daughter watches them, mentions the site to dad, and Mr. Khan gets an offer to start Khan Academy in Silicon Valley. The site has more than 4800 tutorials (including an MCAT prep course), and it is only a matter of time before medical education will be included, making it fast, easy to understand, and free.

    Khan Academy also uses the concept of “flipping the classroom.” Students watch the online lectures for homework and answer questions about the material immediately. Their teachers evaluate how each student did on the homework questions, and then customize each day's lessons to help them focus on areas where students are having difficulty. Imagine if we could do this with residency education. I would absolutely love to get rid of the you-must-have-five-hours-of-lecture-per-week-or-lose-accreditation rule from the Residency Review Committee and instead customize each resident's learning to areas in which he is weakest.

    Two entrepreneurs are rapidly changing the emergency medicine education landscape. The wonderfully sarcastic Mel Herbert, MD, has a new review website, HIPPOEM (as in Hippocrates, not the animal), that covers the nuts and bolts of emergency medicine in a fun, laid-back style that allows viewers to test their knowledge immediately. Lectures are short and to the point, and results can be tracked and analyzed to find out which areas students know and which need some work. Check it out at

    Adam Rosh, MD, the emergency medicine program director at Detroit Receiving, just came out with his in-training test preparation website ( It turns the tables on learning by providing the questions up front and detailed answers with references immediately on the back end. It also allows program directors to track how individual residents and entire classes are doing in a given subject area.

    The future of EM residency education is happening right in front of us. This is only the beginning, and it is just a matter of time until conference lectures take their place by the stethoscope, an outdated relic of the past.

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