Teaching for Retention
Case conference content too often goes in one ear and out the other. We need new strategies to make sure that residents retain what they're learning.
This is part two in a series of pieces on how case conferences go wrong and what we can do to improve them. For part one, click here.
In a week of hour-long case conferences, harried residents hear five chief complaints, five diagnostic workups, five treatment plans, and five disease reviews (at least). The number of learning objectives, flowsheets, protocols, and guidelines climbs into the dozens, if not beyond. All this while residents arrive late from emergencies and long-running rounds and are pulled away by urgent pages and new admissions. Is it any surprise that a week later they struggle to remember what all those conferences were even about in the first place?
Residency programs are spending an enormous amount of time and effort—and consuming residents’ working hours each week—to produce case conferences that do not achieve their most essential goal: teaching clinically relevant information that residents will remember and apply in the course of patient care.
As I discussed in the first post in this series, part of the problem is conference length. We often default to hour-long conferences because one hour has become the standard didactic length throughout medical education, but it is simply too long for adult learners—let alone distracted and exhausted residents—to sustain attention. When residents tune out, the information they are supposed to retain never reaches them in the first place.
A related issue is our goal of covering an entire case from start to finish during a single conference. Into that hour we cram everything: the way the patient presented to the emergency department, their initial lab results and vital signs, the diagnostic plan, the relevant differential diagnosis, the results of the evaluation, relevant society guidelines, the treatment, and the outcome, often with tangents to discuss medical school biochemistry or of-the-moment research.
Not all of that is intended to be memorized, of course. But even if we take the generalizable parts that form our learning objectives—how to evaluate a particular sign or symptom, how to craft a differential diagnosis for a particular complaint, and how to treat a particular illness—we are delivering a volume of information that even the most focused resident would be unable to remember.
Just as we need to reduce the duration of conference if we are going to hold the audience’s attention, we need to reduce the amount of content shared per conference to a level the audience can retain.
As we make conference shorter, we can spread a case across multiple days, or even an entire week. Imagine a case for which Monday is devoted to the initial presentation, Tuesday to the differential diagnosis, Wednesday to the diagnostic evaluation, Thursday to the treatment, and Friday to a summary review. The information delivered each day would be reasonably digestable. Each subsequent day would ofer an opportunity to promote retention through spaced repetition and spiral review. And residents would be better incentivized to attend conference each day so they wouldn’t miss any parts of the serialized story.
The cost of this model is that conferences would cover fewer distinct diagnoses each year. That breadth, though, is an illusion, since the compromises made to achieve it—conferences that are too long and too densely packed—mean that the content was never truly absorbed in the first place.
More to come in this series about how to make conferences memorable, including how to introduce meaningful participatory activities and incorporate spaced repetition.