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0:00
it wasn't long before I realized it's all failure so all of those sessions that we did it's just so powerful you are constantly thinking about kidney pancreatic eyelid beta cell myocyte alveolar you're just thinking about those things in a way I did not before as a physician not in as complete of a story as we talk about when we're teaching it absolutely makes you a better doctor well it looks like a number of you have not yet subscribed to the channel what we're trying to show you
0:32
is that medicine is not a number of disconnected facts it is a way of thinking about your patient the more that you can start with your patient and have a story that runs through pathophysiology the the better you will perform in your exams and the more performance you'll get when you have to do your patient evaluations so make sure to subscribe well good morning everyone today we have a special guest this is a very old friend and a teaching colleague we've been through all the wars together
1:03
and so it's my great pleasure to introduce to you Doctor Eric Nielson welcome Eric such a pleasure to be with you Philip as always let's just talk about why this is a special guest Eric was teaching the simulation lab at a Caribbean university when I was doing their step review course and this was basically going through 8 systems and failure and one day he just cruised in to see what the new guy was talking about and grabbed me afterwards and made me basically spend two hours
1:34
teaching him my way of doing heart and this is a trimester system so every semester when I came back we would spend an afternoon together and he would learn a new system it's not like he didn't know it I mean he was teaching SIM but there's nothing like having someone walk through giving their thoughts about how they see it and then every day he'd go to his SIM lab with the students and he was using it so he became more and more convinced how powerful this was and then finally
2:01
he'd been through all the systems and we got a contractor review that just was more than our thing and I said to Eric would you just do it and he went I'm ready to go and so he actually started teaching the program himself and three or four times later voila there were two of us so that's a really good story and I'll let Eric now pick it up with the story of how he's gone back and forth between private practice and teaching and I'll sort of try to keep them online
2:29
with some of the themes we're developing here and let her rip so Eric over to you thanks so much Philip and again it's always you know so fun to hang out and talk and there's only three of us right yeah exactly there are about three of us um yeah so you know I've made this big transition sort of back to you know majority clinical practice after teaching you know pretty much exclusive teaching and teaching basic science for for more than 10 years um
3:04
you know it was sort of a personal slash professional uh transition as as most things are in life and didn't you actually come out of med school and go into practice I came out of med school and I practiced for about a year but you did a residency yeah oh yeah oh yeah yeah yeah I did family medicine residency and and a component of that residency was uh global health tropical medicine and I spent some time in um Subsaharan Africa basically uh doing rotations and and
3:36
really wanted to incorporate that as part of my career straight out of residency yeah well that must have been a walk on the wild side yeah that was uh very interesting and challenging for many reasons uh amazingly rewarding what brought you back from so a a big component of that job but it was with the Peace Corps a big component of that job was teaching um at at a university um I thought it was gonna be mostly seeing patients with the the sort of uh needs um
4:11
obviously there was a teaching component that was a big part of the program but it turned into you know mostly teaching and I just really liked it um it was really hard it you know I I didn't really know what I was doing I mean you teach medical students and residents you know through training but but um you kind of just teach them what you know and what you you were taught and that's what you got um so so I I I really started thinking about making teaching a big part of my career and I um
4:46
basically went back to my medical school and taught for for 10 years what was in the Caribbean yeah exactly this is in the this is in the Caribbean well there's gotta be a woman in there somewhere yeah as I say I I had an amazing mentor who you know she's been on the show with Nancy right oh I've I've I've seen the show Nancy's been on twice so yeah you can actually say her by name I keep uh you know this is one of my regular programming here you know for sure me too one of my Sunday programs is
5:18
you know uh the YouTube and and yeah it just became more and more of a passion and and I I was look you know I was learning more and more it became more and more challenging as I was diving deeper into uh the the real skill of of teaching especially at the basic science level where you're essentially taking you know college students and and really you know trying to turn them into doctors and provide that those foundational principles you know yeah um that
5:50
that are challenging what took you off Dominica uh basically a Hurricane you know
5:57
as it can do um and then you know we floated around a little bit um I taught it a couple schools didn't you get married in there somewhere I I did yeah and some personal you know that matters yeah personal um uh kind of changes uh advances in my life you know and um and yeah the whole you know uh cycle of life or you know whatever however you wanna say that you know um and that you know obviously that drives professional decisions as well but but um you know I I stuck with the
6:35
teaching for about 10 years at a few different places and um both both you know on the mainland here you know in in the United States and also internationally and then you got the big offer from Nancy and and then I got the big offer from Nancy to to go back with that team so what made that offer so over what cause you and I discussed it before you took it right and I said oh this is to go work with Nancy under these conditions that's a gotta do it what is she promise you
7:03
No. 1 working with Nancy you know and and having Nancy as as sort of uh the person in charge is not only personally but even more important professionally remember how frustrated we were at that other med school for the purposes of our conversation having Nancy make decisions about what gets taught and how it gets taught and and the way it's taught is is you know uh night and day compared to the different experiences we've had you know where where the the structure the who gets to teach what um
7:42
it's just such a nightmare it just it you know it's all about um you know the professor the role control the territory control right really TV and nothing about um student learning so you head off to the Bahamas High wide and handsome to work with one of the best people in medical education and you get to own the fifth semester and you just basically did the program right you got it and and basically over the you know the five years leading up to that point um you know
8:17
we had been working together and I had been you know developing my skills with your approach to you know how to really think like a doctor and think deeply and in a really organized way about the the underlying principles that drive you know medicine and and learning medicine just interrupt for a sec one of the programs we got to do was with a medical school in Mexico and they asked us to take their subject based learning and they gave us the evening and said
8:53
why don't you show why they're learning that for clinical medicine correct and you and Ben Doonan did that for a whole year remember that we did I think I'm what you Learned just taking their basic sciences weak and saying let me make you care and and it was really great the students loved it um they they could really see how just taking they could just see how this mattered to a patient the feedback the feedback was just incredible and I think it was because well you know it
9:24
it was just such a new way of thinking about it that seems so obvious once you hear it but when you're in that classroom pounding your head against the table trying to learn factoids about you know desperate yeah you hardly know what to pick there so it's just all those back doors it's just you don't even know where you're going you know correct um so so that you know it was these kind of experiences that you know not only hone your skills as an educator and really you know you just
9:58
you can just anticipate the questions the students are gonna have ahead of time and and you know really develop you as a a teacher but also just you know time and again just show you know how successful this approach is from the student perspective okay so now you get to run the semester it's just you how did that feel yeah I I mean I I think it was um exciting nerve wracking you know this anticipation of a lot of sort of expectation and pressure so let let me just review that for our audience
10:37
this is a brand new medical school this is their inaugural class these are not students that are good test takers and there's nothing in the first four semesters that's reassuring that the step exam is gonna go well so we've you've promised the world this is magic and then they give you the a very challenging group of students to work with and said okay Mister Smarty Pants show us yeah and and I mean all of these groups are are bit challenging right this is the student population that that um
11:10
you work with they're not great test takers it's nothing wrong with the character the skill the intelligence by definition they're just not great test takers and they got this all in step 1 exam and that's that's the rub it's all in right you you've got to be prepared for an exam that is a very challenging exam um and and and here it comes this is the the prep for taking the test and and walking them through you know basically each of these organ systems using
11:42
you know the approach that you've developed that we you know worked together on for so long you know really I think showed them a way of thinking about the the the medicine the questions that they're gonna need to answer on this test and and to do it in a way that's that's that's focused and efficient and that that's I think one of the big challenge of of our students um the test is challenging it's particularly challenging when you have to answer these questions in 60 or 90 seconds
12:15
I mean you you have to have a focused grasp on on this content and it's critical and it's very clinical you could know every fact in first day it doesn't let you start with a clinical question correct you've got to make the diagnosis you know straight off the top and then go back to your you know very organized approach of how to think through these disease processes again from from patient all the way through to DNA where you're gonna be asked one aspect of of that disease process and
12:51
and I think that's where the the power of the program comes in the the power of the approach is you know you're not just teaching them individual facts about diseases it's really an approach to to all diseases how do we think about how it's more for our it's how to learn how to learn medicine okay now you did that for what three years I did that for three years and then as my military kids said you got O B E d overtaken by events overtaken by events so you had your second baby
13:24
and it was time to head back to civilization it it was sort of a a big personal um component this you know as as again as life happens you know yes oh I yes with four kids I'm very familiar very well no yeah okay so but this is really different right because now you're leaving extraordinarily successful professional achievement do you think anyone else in the world has ever done this like what you did with that group I don't know that that was pretty impressive it
13:57
we were all very proud I'll put it that way weren't we weren't we proud and gratified we're so happy for the students they all passed step one every one of them yeah or at least they've made it you know to that to that level where they're well everyone that that did the course and pass their screening exam comp exam every one of those went on to pass step one yeah and I and I think that's that's pretty much all of you know yeah it was so impressive which was so impressive you know
14:29
now comes the magic whole point of this interview you're heading back home into practice yeah what did it feel like the first day you put on the white coat and you walked into clinic what did that feel like you're like I'm back you know um it you know again similar feelings nerve wracking you know trying to get the rhythm and flow of the of that you know different hat you're wearing um and it is a very different hat you know it's it's one thing to to lay out you know heart failure
15:03
it's another thing to to find it in one of those rooms for the first time figure out that is what's going on and what are you gonna do about it it wasn't a SIM patient this time was it no it wasn't a SIM patient this time exactly so you know there's there's a there's that level of anxiety when when you walk in the room and somebody's sick you know I mean and that's always I think there I mean that doesn't it's not just a new thing it's just no I never did a frozen section
15:28
my heart wasn't a little bit accelerated there you go I think that's one of the one of the beauties of this job is it's intense so you're taking 10 years of teaching comprehensive medicine pathophysiology and now you're back in patient care tell us about the experience yeah you know it it just all those memories come flooding back of you know patients you've had and you know being in the office and the hustle and bustle um you know academic life is is intense but but it's a bit calm or intense
15:58
it's a it's a reading intense it's a a thinking intense and and clinical practice is a lot more on your feet you know boom boom boom intense and and seeing patients you know just just brought back that um again just so special feeling and of just taking care of people which is which is wonderful and also just that mental challenge of really loving to figure out these sort of human puzzles you know what what's actually happening do I have it right now tell us that experience
16:34
in the context of someone who is taught patho phys for 10 years tell us about what it was like now that you bring that profound understanding into patient care how are you as a doctor having done that yeah I I think it was it it wasn't long before I realized you know Philip this is it's all failure it's it's all failure so all of those sessions that we did it's just so powerful you are constantly thinking about um kidney uh pancreatic islet beta cell you know myocyte alveolar I didn't you're
17:16
you're just thinking about those things in a way I did not before as a as a physician not not in as complete you know complete of a story as we talk about um when we're when we're teaching has it made you a better doctor do you think oh it uh it absolutely makes you a better doctor it and it's it's it's constant it's every day it's it's thinking about you know where is this person's GFR you know how many nephrons do they have left I mean you're just you're you're thinking about it and
17:49
you have the picture in your head that we put up on the board so many times in the class and and talking about you know diabetes and hypertension and glomerular function and you're you're seeing it um you're you're visualizing those things that we taught you know students in in the classroom in a way that I that I just don't I think I I had I just didn't have the picture in the same way that I do now when I you know was a resident for example you know at first seeing patients I gotta tell you
18:22
I have this vision of myself as a glorified EMT I was just a really sophisticated EMT I you know not that it wasn't skill but I'd memorized a lot of patterns and it wasn't till I started teaching that I realized I would have been a way better doctor if I'd understood why I was doing that yeah no totally um why and and really visualizing again you know I think that the approach is just it's it's so obvious when you think about it but but you want to think about these diseases in an organ
18:55
tissue cell ultrastructure DNA that's that's how the diseases happen and and being able to think and see that picture in the person in front of you just just takes your focus to another level I think when you're doing diabetes early diabetes and you get your albumin creatinine ratio do you actually kind of see the basement membrane filling up with advanced glycosylation end products exactly what it is it's literally what you're doing you can't not right you can't not you can't
19:28
that's exactly the way to say it you you it's not just a number on on a on the lab report you know which which which is so often it is it's you're it's an algorithm it's numbers in an algorithm you're walking through not not a picture a picture of the glomerular basement membrane and you know the the advanced glycosylated end products damaging putting holes in that thing and being able to this you know this is the other thing being able to describe these things
19:58
to patients in a way that's digestible is really does that work to a to a point obviously but you can tell stories I think having done this for 10 years in a way where you're you're honing down what is happening um translates to patient patient care patient education you know so those those kind of things um you know you especially family practice job you know you're teaching patients all day you know you're you're validating what they've read online you're explaining things again it's it's
20:33
it's the clinical environment so it's busy it's stressful you're seeing a lot of patients there's a lot going on um but but these are ways to to make an impact and and to walk out of a room and have the patient you know go home and and really have a better understanding of what's happening in their body and and I think that translates to better patient outcomes you know um I how couldn't it okay tell me the truth when you see hypertension do you in your heart feel a little anxious about those
21:04
lenticulostriate arterials exactly exactly it's not just theory right you can see that little micro aneurysm in that little big you you can see it and and when you're getting that you know MRI and the radiologist is reporting you know hyper densities uh uh indicating likely chronic ischemic changes it those aren't just words on a page you're seeing it you're seeing the picture in your mind how much do you love jugular venous distension these days I do fortunately I don't see it too often
21:39
but but do you see the veins you don't just look for the bulge anymore right yeah exactly yes and you know I don't think I ever teach that I don't learn something so I was teaching diarrhea yesterday and I always thought one of the most useless discussions I ever had was the mechanism of diarrhea in Vibrio cholerae I mean not that it's not a historically really important disease is still prevalent but in my mind I had always memorized o cyclic amp goes up
22:08
because that's always the answer in multiple choice right except that you know teaching changes us when you teach this way it changes you and I realize why have I just got a fact in my head why don't I go through and understand what really happens okay hang with me so we get the cholera toxin which goes to the receptor that activates my G alpha and that's why cyclic amp goes up okay great then but then I asked cause it's us now doing this completely
22:38
so what does cyclic amp have to do with anything and you know what it acts on the CFTR channel wow it it's so well wait it's gonna get better so now it goes to the CFTR channel out goes the Chloride sodium osmotic diarrhea right totally so a student I'm talking to a student about this and she asked me this question cause we got on the topic of cystic fibrosis so do they have less severe diarrhea in cholera cause they haven't got a working CFTR yeah do you know what the answer is yes it does
23:13
that's right and the whole art I looked it up cause of course you're always looking I looked it up and the article discussed how okay it's really bad for the homos I get little kids but if you're just a carrier it probably was a survival advantage color was that important in the past yeah and it was just one of those hair on fire brain exploding that's the greatest thing I've Learned all day yeah it's like a like like malarial sickle cell right right so
23:42
I've been teaching that disease for over a decade without that really good story in my head yeah and now you can't forget it you know no I'll never forget it yeah so tell me a good disease you seen recently that you went God I'm smart I just love I'm so smart cause I've taught this what have you seen recently that gave you a wonderful good for me story you can think about it while we talk even even yesterday I mean the m the MRI is from yesterday you know I mean yeah
24:08
you know the subtle mental sort of um what would seem like a vascular dementia type of picture and um you know step wise type of regression that happened pretty rapidly obviously it's a you know sort of older person and you're wondering if the story was as rapid as it seems to be or if this was a you know more slowly gradual decline and you get the MRI and and you see hyperdensities walk us through that for your audience so you know vascular dementia is is this you know arteriolar
24:50
so you thought our hypertension not amyloid vasculopathy correct and um and and you're you know looking for those type of changes when you order the scan versus uh say you know global atrophy if it was more of a an advanced dementia or you know particular uh um potentially ventriculomegaly say for example if it's HIV yeah normal pressure hydrocephalus or you know so you're thinking through this process talking with a you know a family member and a patient and you know you have your suspicions
25:29
you're enjoying looking at the testing because it's all patho physiological for you correct didn't you wish you had some of your students to show them and talk them through testing teachers map of this I can't wait till I get students you know I can't right it's just this irresistible urge to say see that exactly and and explain that you know how's that work right and and and you bring a totally new brain to the experience yeah and I think just a a different perspective that that again I
26:01
you know most students I I do not think are learning this way um I've I've interacted with a lot of students at many schools you know all over the world really from Rwanda to California and and they're still sort of stuck very much it's changing but still very much stuck well we we say we say we're trying in a in a discipline based side load thing because that's that's what most of us feel comfortable with we stay in our lane we don't wanna teach outside our lane you know probably for
26:40
for good reasons we don't wanna you know say the wrong thing or teach the wrong thing or but also there's turf war and you know yeah it's just why have that unpleasantness and the risk of embarrassing yourself that's right right you and I have embarrassed ourselves so often I'm sort of past it now every day you know I mean it's it's just a thing you know that you just yeah don't even flinch at you know so you know yesterday obviously I was teaching diarrhea right
27:07
and this was my great insight just to show students how I mean we've been doing this for over a decade this was my experience yesterday so it was the first time I had a little time to think about it and so you know normally I just do it as a paragraph yeah so more than I did I made it an algorithm and so for the first time I sort of done acute chronic and then I worked out with my diseases and as I looked at it I can't believe it everything acute is microbiology and chronic is pathology
27:36
yeah and I thought wow if our students would just take diarrhea in the GI system they must be able to do 70% of all the organisms they have to know all with a good story of how to think about them in a cute diarrhea setting yeah and I taught it that way Eric it was so much better so I I will send you the algorithm and you look at it and go oh my God it's micropath what were we doing I'm gonna put up on the wall and and have the students tell me about diarrhea you know
28:05
and see let's see how much of this how much of the you know approach can they get you know have you had any experiences clinically now you say oh I I could teach this better now that I'm back reminding myself of patient interactions has anything come to mind not really to be honest are we doing that well are we I well I I think so to be honest I really think so I mean I always talk about you know the clinical side it's it's the pleasure of of working with and helping people you know
28:35
it's it's sort of that you know altruistic thing that flows under all of medicine you hope you know in in so many ways you know why so many people get into it um I I think the main thing about the clinical and teaching is just it's just the street cred as as you say it's just being able to go from the office right in the classroom and say I I just saw this yesterday and and that's so powerful for for a medical student uh for any learner to see what they're learning in the context of
29:09
of who they're gonna be and where they're going failure is dominating your practice failure is dominating the practice so diabetes hypertension what else you seeing that just Matt you just gotta do all day every day the the ramifications of that you know heart kidney um there's a lot there's a lot of COPD emphysema a lot of asthma do you have office PFTs I mean in in being able to explain that to patients so you have an office spirometer I we don't no not not a pulmonary function test
29:42
just a peak flow sort of thing for a Q well I think the question is you know and then what am I gonna do with it but you know I I would love one if if I knew how to use it and could you know well but I mean I've never worked we should look that up how much fun would our students watch you and me figure out which one to order we'll put it in the office and then we'll I get your patient's permission and we'll video you teaching yourself to use the cotton picket veil you're amazing I mean I know
30:11
Ali would say that's the greatest content of all time but you and I would think that's pretty funny yeah yeah how about ultrasound do you feel like a wanker that you haven't got great ultrasound skills yeah more and more um more more and more it's just it's just become even family practice you know how are you gonna teach yourself well I've got some sports medicine guys upstairs who are who are all about the ultrasound yeah and uh they're they're great guys and they
30:41
they're avid you know teachers they they really wanna spread this knowledge and technology make me a promise yeah yeah you will keep track of you your painful early learning of ultrasound so we can all let our students know we're all useless don't ever apologize for being ignorant just apologize for not getting better yeah that's that's the point right so keep track of that learning phase of what it's like to be useless it's it's learning you know you feel very useless
31:13
I mean you feel like you're you're you're right I hear your body yeah exactly you say stupid obvious things right it's called learning you know I mean yeah you know give your phone when you first pick up that ultrasound and they say please put it there get someone to pick up your phone and you go where and they give you the look well there you idiot can't you see that right in front of your face you're not measuring the median nerve in the carpal tunnel you're measuring you know the
31:43
what's wrong with you yeah yeah our students need to understand how that's all don't let that stop you from getting better yeah it's it's it's a huge hurdle for for for many of our students especially the students we we teach you know they've been beaten down by these exams for a long time and and confidence is a huge piece of of doing well you know in medicine in general but in these exams in particular the pace of the exam it it just it it just you know feeds on your confidence
32:18
and the minute that starts to slip you know I I see it over and over with students that the scores just just go down it's a death spiral isn't it it's a death spiral even though the students know the content they know the right answer they get into that test and they just they start to doubt they just start to doubt anxiety and then the fog it just crushes them and the one good thing I've always believed about what we do is I mean after two years how could 42 hours of review help at all
32:52
except it tells you there's a plan and so when you practice that plan when you feel that that anxiety and the fog you go no let's go back to basics age gender time frame find the chief complaint what's the difference you know you can you it gives you a tool for that sense of inadequacy absolutely you have an approach you know and I think the more students just have that just drilled in they go up to the board they draw the picture they they explain and talk it out um
33:27
that that's the answer is there you know and and that's gonna be one of the multiple choice answers they just they just have to have the confidence to pick it you know what I have the biggest trouble convincing students that the best way to get ready for your exam is to get ready to be a good doctor so when I say to you here's our program do you use it every day in your patient care every patient in the patient care I mean you know basically every patient I mean
33:57
you know sprained ankles and stuff I see quite a bit you know that not necessarily a ton of uh patient to DNA in that in that encounter
34:09
you know yeah it's it's more anatomy and inflammation and you know I mean there there are some key principles there still but um you know every other patient every chronic disease management patient which is so many of the patients I see it's it's and it's not even just one thing it's it's a multiple things it's you know five or six of the of the core you know disease principles we've we've talked about in in let's say a review course or um whatever are are in that patient
34:42
where do you see this going right now you've got a really young family you've got you know it's just a work part of your life you got a nice job where you wanna live uh where do you go from here yeah it's a it's a great question I I think I I haven't let myself go there yet well it's pretty new I mean how long you've been back in practice three or four months I mean yeah three months you know first of the year just for the audience sake you should understand you know Eric and I live together
35:06
through all these teaching programs so you're watching us catch up on each other it's like I remember all the bread that you've missed so a lot of this is just catching up yeah so yeah so just three months um you know I obviously I'm I gotta get students into the office you know that's that's sort of the the next big step and and I think you know come the the start of the school year in August I'll be settled enough and you know I'll I'll get a student into the office at least
35:34
you know once a week or what you know whatever the whatever the rotations you know work out well you know obviously what I'm excited by is I want you to come and work in our new website so you know you can see that you bringing this to our place of I've taken our teaching to practice and now I'm gonna tell you about my experience with students in the office I'm really excited I wish I wish Ali would get now is getting our website going
36:05
because I you know I think that that's something that everyone really wants to hear is now transitioning from basic sciences classroom to you teaching it in clerkship yeah I it it does feel like you know the next step you know at least for me in in my in my teaching development well we've always wanted to take this into clerkship yeah that's you know we know so much of the learning of a medical student happens in that third year um you know the first two
36:34
so many students just memorize crap and blow it off first aid first aid in New World first aid pass the test when I get to the hospital then I'll really learn stuff you know this is the in the mind of a of a medical student and then they get there and they're they're floored you know the third year is a big year sounds like then we should catch up with you this fall I would love to catch up this fall you you gotta do us the joy of as best you can recording
37:02
learning ultrasound and you being the new guy I I will do that we'll say you know turn the other way it's upside down you know that that kind of yeah yeah other left right yeah exactly okay well this has been great I I hope that the recording's gone all successfully with Ali um we'll be in touch and um no later than this fall yeah sounds perfect I'll I'll I'll I'll capture that video best you can thanks Philip bye bye if you are a medical student and you want to learn medicine from your patient
37:37
centered doctor's perspective here are things you must do first if you want the whole universe of my thinking you can get the textbook click the link in the description second if you enjoy the podcast you can go see my earlier podcast with Doctor Selfridge see you next time
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