Sorcery Not Necessary: EHR Curricula and Deliberate Practice for Medical Students

By: Leland D. Husband, MBA, MS, M3, University of Mississippi School of Medicine

Last Friday, my class had its senior-year planning meeting. It’s the meeting where we learn how to apply for away rotations and residency, plan our fourth-year schedule, and deepen our worries about specialty selection. The day began with a welcome from the vice dean, where she relayed her excitement about our progress. We shared the excitement. As a challenge, our day was divided into PowerPoint, paperwork, PowerPoint, break. Somewhere in the PowerPoint–paperwork–PowerPoint–break stream, something strange happened. Students engaged a speaker. They asked questions; they paid attention. Some might claim sorcery, whether through the topic or speaker or in the air, but I assure you, no mysticism took place. The talk was boring, routine—an electronic health records (EHR) update.

The update covered a change in our EHR to let students write orders, save them, and send them to an approving authority. Despite complaints from some students and faculty, we’ve always been able to write orders; we just couldn’t sign them. Instead, we had to “pend as medical student,” then hope the approving physician could navigate the maze of clicks to find the buried order. Now, orders were to be part of the student and faculty workflow, making the process straightforward. Undoubtedly, students will engage the EHR more effectively. The EHR update held our attention because it was practical; it offered a way for us to engage our clinical education.

At times, it feels like there is little a student can do to help patients or treatment teams. We sit; we listen. We stand as our patients’ advocate; we investigate every deviation from the norm. We write notes and pend orders, but will the team be able to use them or will they disappear into EHR ether? Milano and colleagues and Wald and colleagues note in the March issue of Academic Medicine that EHR are integral to health care today; they improve care, but they could leave students behind. As students, if we’re to be the future, then we can’t be lame out the gate.

Both Milano and Wald provide examples of successful EHR curricula. Both curricula recognize the need for deliberate practice and focused feedback. Milano merges EHR with chronic disease evaluation; whereas Wald examines the softer, more humanistic qualities that we must maintain as EHR become more integral to medicine. Though both offer quality training and practice, I wonder if the quantity is enough. Do students get the same benefit from failing in a classroom as they do failing in the clinic? Does the classroom offer the immediate, rapid-succession feedback that sculpts behavior? People say you learn the most as an intern and your first year attending. I suspect the rapid learning is from the increased practice quantity and quality. The intern and attending receive immediate, rapid-succession feedback, a fundamental of deliberate practice.

Practical training simulations—patient interviews, running a code, EHR, or any of the hundreds of competencies students should master before graduation—build competencies while keeping students’ attention. But to maximize the benefit, students need to push beyond their limits, fail, and try again. Instead of large assignments and protracted small group discussions, what would happen with smaller assignments and a shorter timetable? What about making it a game?

Milano and Wald tackle a difficult problem. They provide frameworks that other educators may build upon. They do what any good coach does—take students a step closer to mastery. We all want to be masters, but don’t forget, (paraphrasing a mentor of mine) “you don’t do a 100 liver transplants in a year by staying in bed.”

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