Thinking About Ob/Gyn
A fresh and evidence-based perspective of all things related to obstetrics and gynecology. Follow us on Instagram @thinkingaboutobgyn or visit thinkingaboutobgyn.com for show notes and more.
Thinking About Ob/Gyn
Episode 7.11 IUD insertion, teaching residents and students, and the history of blood transfusion
In this episode, we discuss four tips for IUD insertion. Then we discuss the qualities of good teachers and the important of teaching students and residents, with some practical advice thrown in as well. Finally, we discuss the history of blood transfusion.
00:00:02 IUD Insertion Techniques and Anxiety Management
00:23:04 Qualities of a Great Teacher
00:35:16 The Benefits of Teaching in Medicine
00:45:42 Teaching Strategies for Clinical Preceptors
00:52:33 History of Blood Transfusion & Obstetrics
Follow us on Instagram @thinkingaboutobgyn.
This is Thinking About OB-GYN with your hosts Antonia Roberts and Howard Harrell.
Howard:Antonia.
Antonia:Howard.
Howard:What are we thinking about on today's episode?
Antonia:Well, we're going to talk about teaching, but also for our historical tidbit, the history of blood transfusions. But first it's time for our four tips segment and we're going to cover IUD insertion. So social media, and TikTok in particular, is full of horror stories about IUD insertion. That, more than ever, I think, is scaring women away from what really is the best form of birth control. And there's studies that have looked at pre-medication with various pain medications or anxiolytics or nerve blocks like paracervical or intracervical, and none of these studies have really shown the most earth shattering results and a lot of gynecologists really don't see significant pain with most insertions even without using any of these methods. Tell their friends and, in some cases, just tell the whole world on social media, and then it makes it seem like it's excruciating for everyone rather than for a small fraction of people.
Howard:We've talked before about some of these preemptive strategies, which include cervical ripening with mesoprostol prior to placement, or giving a anxiolytic drug like a benzodiazepine 30 minutes to an hour before insertion, or having the patient take a narcotic or anti-inflammatory medication prior to insertion, or even doing intra or paracervical blocks with lidocaine or something like that, or a lidocaine gel that you can put on the cervix, and some people will even take lidocaine in an insemination catheter and put it up in the canal or into the cavity. So a whole bunch of things have been talked about. There have been trials of most of these things. There's been trials of lidocaine applied to the cervix prior to insertion. Before you put the tenaculum on things like that, Well, I hadn't heard of inseminating with lidocaine.
Antonia:That seems a bit aggressive. But unfortunately for the other things I think I've heard of everything else you just listed In those studies. If you control for all other factors related to the insertion technique and only assess the effect of that one pain relief intervention, generally there's little to no improvement from that intervention for most patients and I think there truly are some patients who can get significant benefit from one or more of those methods, but that's not really the case in the general population.
Howard:Yeah, and then we have to be careful not to generalize some particular patients who might have success with the general population and apply those results, because in some cases, through upregulation of nausea, reception and things like that, you might even make things worse for patients or increase their anxiety.
Howard:But I definitely agree that for selected patients it's very feasible that incorporating maybe a paracervical block or a pre-procedural anxiolytic like Valium or Motrin or something like that could make an IED insertion tolerable for a person who might otherwise not have been able to tolerate it.
Howard:So a good example might be a patient who's had difficult gynecologic exams in the past, for whatever reason. Maybe they have endometriosis or dyspareunia or they've got concurrent pain for some reason or pelvic floor tenderness, or maybe they've already had a prior horrible experience with an IED insertion but they still want to try that method. Experience with an IED insertion, but they still want to try that method. And what might feel like milder discomfort to one patient could be particularly horrific and traumatizing to another patient with a history like that and they may just have strong anxiety about the procedure on top of everything else. So there's definitely, I think, a patient who could likely benefit from premedication with, say, an anxiolytic. And if she's having an IED removed and you can't see the string and you think you're going to have to use tools in the uterus to go up inside the cervix or the cavity, maybe multiple times, then sure it may be more beneficial to go ahead and do a cervical block.
Antonia:Yeah, we just always have to balance that against the risks. So we know that injecting an anesthetic in the cervix with a needle itself is painful and in most cases with a straightforward insertion, removal, something like that, it probably would hurt more than the actual procedure itself. So in most cases it's not really worth it. And then there's always the theoretic risks at least, of some kind of rare reaction to the anesthetic as well. So right now it's not recommended that any of those pain relief methods be used as a universal practice. So really, like everything in medicine, we just need to look at the patient in front of us in addition to the best evidence that we know of when we're caring for them.
Howard:Yes, I definitely think you can individualize it, as you said, for the particular patient, but right, universally. Most of the pain and discomfort preemptive strategies we've talked about aren't effective, and if you think about the pain and discomfort that patients have, I think they primarily come from two sources, and so one is anxiety itself, which heightens the pain response, and then the second one is just poor technique.
Antonia:You could probably say the same thing about pap smears that are painful, because there are women who even will tell you they had the most horrific pap smear, and you can only imagine that a pap smear is not supposed to hurt. So if a pap smear hurts for someone, then either they were highly anxious about it and were just clenching and couldn't bear even the lightest touch, or they had a really bad technique, or maybe both. So how much more so for something a little bit more invasive than a pap.
Howard:Right and so yes, if a pap is going to be painful, then certainly an IED insertion is going to be painful, and I do have some patients who require premedication in order to receive a pap smear or a pelvic exam, but certainly most women don't and would not benefit from that.
Antonia:Okay, so into the four tips, it'll mostly center around the technique, but the first tip isn't really a technique per se, it's managing the anxiety. So why don't you explain more about that?
Howard:Well, for starters, it means something that I think might be surprising to some of the listeners, and that is that we should try as often as possible to insert the IED on the same day as their initial consultation or visit. So it's very common to have patients who have a consultation visit first and then return the next week or sometime later to have their device inserted, and this is unnecessary, and many patients don't return after they spend some time on social media learning about these horror stories of insertions that we're talking about. It also, doing this drives up the cost of care and just inconvenience for a patient. I think about all the things that I do clinically and through the filter of the triple or the quadruple aim. So, if you recall, the triple aim is to reduce the cost of healthcare, improve the patient experience and improve population health.
Howard:Now, if you have the patient come back for a second visit at some later date, that increases the cost both to your clinic and to the patient, and maybe she's missing work, an extra time, maybe a whole day, a second time, paying for child care for that extra visit, or even just traveling to the clinic for an extra time when she could have been doing something else. And in an ideal world, if billing worked and insurance companies work the way we would like it to, then the clinic shouldn't make more money by dividing the visits up. But in practice a lot of times the fees reduce. So sometimes that's a negative incentive for clinics to part this out over two different days. But when you do that, you're taking away a slot that could have been used for another patient who needed it.
Howard:So this is an issue for medical justice in terms of providing access to patients. And then, of course, that's assuming that the patient that you want to put the IED in even comes back for that follow-up visit. Maybe she isn't able to arrange the second visit and ends up with an unattended pregnancy instead. Or maybe she's so scared about TikTok that she just cancels. And maybe she schedules a follow-up but then she doesn't show up or cancels. And if you order IEDs in advance, as many clinics do that do separate day placement, then that IUD may get discarded because it's not for her anymore, and now your clinic loses more money and time because the slot's not utilized, etc. So this worsens population health on many levels to break these visits up.
Antonia:So yeah, the traditional way, how you said, where we have the initial visit counsel about the IUD and say, great, now we have to order it and then we'll bring you back said where we have the initial visit counsel about the IUD and say, great, now we have to order it, and then we'll bring you back here once we have it in our office.
Antonia:And from switching from that to just having IUDs in a standing stock of them, I think one concern might be like, if the clinic puts up the money up front to get these IUDs, how do they know? Will they all get used or not, or will some of them just expire and have to get discarded and be just a loss if they end up buying more than what the demand was? But it sounds like even that loss could potentially be offset a little if they did these same day insertions as a policy and then freed up the time to get more patients in, like you were saying, more access. And not only that, but there are programs that have thought about this and are out there to help clinics project just how many IUDs or Nexplanons they should buy to make sure that they don't end up having a loss of having two more than what the demand is. So that's something we can put a link to. There is a good ACOG article about this that also gives a good link.
Howard:And, by the way, acog recommends that we all strive for same day placement.
Antonia:Right, yeah, exactly. And they talk about exactly the coding of how it should be the same payout on the same day instead of two different days. But yeah, like you said, insurance doesn't always agree with that, apparently. But if we do it the traditional way, where there's a built-in obligatory delay between the decision for the IUD and then placement on a different day, there's so much time for the patients to second guess this decision, especially if they talk to the wrong person or go down the wrong internet rabbit rabbit hole about it and then assuming they do, come back in they're going to be very anxious, whereas the people who just talked about it decided and then had it placed within the same 10 minute period don't have time to go scrolling like doom scrolling and hearing the worst of the worst.
Howard:Yeah, exactly, and if you can counsel your patient in a way that shows that you have confidence about what you're doing and that you have experience and that IED insertion is a normal and routine thing, not something exotic that we have to plan for, and if you have good technique and it doesn't take long to get everything ready and to get the placement done, then they'll have a lot less anxiety and that, I think, is the first step to reducing pain with insertion.
Antonia:Okay, so we're still on our first tip. So reduce anxiety by instituting same day availability and by projecting and reassuring that you have good technique and obviously having good techniques. So our next tips are going to be about that. So tip two is either don't use the tenaculum at all or just use it halfway like a hook where you're only using one of the teeth.
Howard:Yeah, a lot of the pain is because physicians take that tenaculum and clamp it across the anterior cervix as if they were in the operating room and the patient were asleep and they were doing a DNC or something and this frankly hurts. And if you're going to do this routinely, I can understand why people are interested in getting numbing medicine or cervical blocks, and actually I think that the main thing that the numbing medicine helps relieve pain for is this clamping across, not the actual insertion. So this is a moment that many patients will feel and experience and talk about as being horrific or barbaric. There was actually a piece in the New York Times yesterday about this barbaric instrument, but this is mostly an unnecessary step.
Howard:I have put in many thousands of IEDs in my career and it's incredibly rare that I use a tenaculum in this way at least. So instead I either don't use a tenaculum at all and that's the norm, especially for patients who are six weeks postpartum or I just use half of it as sort of a hook that I place against the os, the inside of it, and that will help me provide some traction. And if this doesn't work and I still have to use both sides, I don't usually clamp it down, but I apply the least amount of pressure in closing the tool as necessary to provide that counter traction, and I only do it while the IUD is being inserted, not before, so that they have that one experience, not two.
Antonia:So the next item on the technique is sounding. We talked about sounding the uterus before I think in season four as a thing, we do without evidence for IUD placements, and so the next tip is don't routinely sound the uterus, but a lot of training about IUD placement. That goes through the package insert technique. That's listed.
Antonia:If you open up all the fine print, that includes placing the tenaculum fully, clamping it across the front of the cervix, how you described, and then putting in the sound, which is I always describe it as a little measuring stick that goes inside the uterus. And then it also talks about other unnecessary things, like you have to use sterile gloves. That also is you're not going to touch the IUD, so you've actually don't need to do that either. So essentially the whole thing, if you look at the package insert, is turned into a surgical procedure and think about all of the extra time, extra equipment, the whole process involved. You have this whole setup that is going to look very daunting for this patient who's awake in your office. That's going to increase their anxiety for sure. So how long does it take you to insert an IUD, let's say, in a postpartum patient, from placing the speculum to being done and having the speculum out?
Howard:Yeah, usually less than a minute for a postpartum patient.
Antonia:Yeah, and there's no way. If you followed the package insert, it would probably take you like five or 10 minutes at least, and I'm sure it takes a little bit longer for patients who haven't recently pushed out a baby through their cervix. But another point about reducing anxiety is having less scary looking instruments sitting in front of the patient that you're about to use. The protocols for IUD insertion in the original documents as described, are not actually based on scientific evidence. They were just designed decades ago and we had less experience and understanding with the insertion process.
Howard:Yeah, the package insert is not the place to learn the correct technique for placing an IED. I'm sorry.
Antonia:Yeah, okay. So on this tip about not sounding the uterus, we still need to know what the size of the uterus is. So how would we know that without inserting the measuring stick in there?
Howard:Right. Well, we're still sounding, but we're using the device itself as the sound. It's got numbers printed on it. It's actually better than the metal sound you can't see. So when you place the device, you're essentially sounding the uterus with the device, and then, when you've done that, you can pull back and release the wings per the instructions and set the device all in one smooth step, rather than making the sound first, followed by the IED placement and two separate passes through the cervix and that internal cervical loss.
Howard:The IED insertion inserter is more flexible and a little bit larger diameter wise, than the sound is, and so this should lead to less perforations. But the main thing is it leads to less pain because everything happens at one step, at one time. With the technique I'm describing. There is no tenaculum stuck on the cervix hanging out while you switch around instruments, and then all the anticipation of the next painful thing that's happening after you've just snatched that thing across your cervix and then the sound follows and then you got to do the IED. You've really got three pain points here that way. So I can't recall the last time I sounded a patient with the uterine sound in the office.
Antonia:There are actually some studies backing this up that show the sounding really is just unnecessary. And let's say you have a patient who's never been pregnant and the cervix is very narrow, much more narrow than the inserter. And let's say you start putting the inserter in and you just can't get it past. You still don't need to sound. You need to dilate the cervix and you can do that with the little plastic dilator that's tapered really thin on the tip and then slowly gets wider it's the internal cervical os, that's the most important part on the tip and then slowly gets wider. It's the internal cervical os, that's the most important part of this. And you may just need, or you may just need, to navigate. Maybe it's not a straight line, but if you can find that pathway with the os finder then you'll be clear to put the inserter in. But neither of those require using either that metal sound or the little plastic sounds.
Howard:Our office has some of the plastic sounds too, but yeah, you're just increasing perforation, risk going any higher than that internal loss. Yeah, so my other point about all this is that the whole IED insertion for me I try to make it one smooth step where I try to place the IED without a tenaculum, but I have the tenaculum in my hand ready to go, because I used it to hold the beta-9 swabs when I cleaned the cervix. And then if I meet any resistance with the IED inserter, I'll use the tenaculum at the same time, without removing anything to provide some counter traction, and I apply just as much as is needed for the IED inserter to transverse the internal cervical loss and then I take it off even before I cut the strings. So it's one smooth step where all of the painful sensations happen at once and I use only the amount of pressure that's needed rather than universally applying maximum carnage to every patient with that tenaculum.
Antonia:Okay. So managing anxiety, don't use the tenaculum the full way, don't routinely sound. Our last step is to gently pull the cervix to straighten the canal, and I'm saying this as a separate step, even though we just said don't use the tenaculum if you can avoid it, but if a patient has severe uterine flexion forwards, backwards, whatever, you are going to need to use something to straighten out the path for the IUD. So, besides how we talked about using just one side of the tenaculum as a hook, there are some alternatives you could consider too. There's tools that don't have a sharp tooth that pokes. Some people have used a long Alice clamp or possibly even a ring forcep or the smaller Randall stone forceps, and then I saw there's a newer device being tested that basically uses vacuum suction in the shape of the cervix instead of something sharp and designed specifically for pulling traction on the cervix for IUD placements.
Howard:Yeah, it's undergoing a new trial. Initial trials of a previous iteration of it in Europe had a lot of problems, but it's been redesigned and we'll see what that shows. And it's at least nice to try using something less sharp to straighten the cervix. Sometimes I see articles and posts that talk about how little attention is paid to women's pain during these procedures and gynecologic procedures in general, and at least in this case that's not true. If you search on PubMed, you'll find countless studies on how to decrease IED insertion pain. If you search on PubMed, you'll find countless studies on how to decrease IED insertion pain. Some people will also have the patient bear down or even place if they're anti-flex, put their hands at their suprapubic area and push while they're putting the IED in.
Howard:People have tried all sorts of things to avoid what we're talking about, but the disappointing truth is that at least in randomized trials these atraumatic tools like Alice's and these things they don't reduce pain. Now, as far as that vacuum device goes, as I said, we'll see it's a creative idea. If it works, I'll be happy to use it, maybe not on everybody, but on the patients we're talking about. So the larger US trial of the redesigned device is underway, and so we'll see. This worked obviously better in the initial trial in nulogravity patients. I think that's where the main benefit would be, and if this works and becomes more widely available, then we'll see how that goes.
Howard:And as I said, though, I think the main thing is that you don't always need to do this step so you can have the tenaculum or whatever tool ready to go. But if the inserter passes easily, then you know the cervix is already straight enough, and this is the case for the majority of postpartum patients and, honestly, even sometimes noliparous patients who are not acutely antiflexed or retroflexed. It just slides right in. But when it doesn't pass easily, you need something to pull, slowly and gently and just enough so that the cervical uterine angle is straightened out, and as that flexion of the uterus is reduced and that's straightened out, the device should pass fairly easily.
Antonia:Yeah. So I guess With this tip you don't have to pull with your full strength down like you're doing a vaginal hysterectomy or something Like just pull a little bit if you need to at all, because, like we said, sometimes the uterus is bent quite sharply over itself forwards or backwards and the IUD insertor cannot bend that sharply Like the way some people's anatomy is. It would be turning back inside the patient's body towards your face, as you're pushing it in the opposite direction of the cervix. That's asking for perforation. So if it's a case where the fundus and the external ass of the cervix are like pointing in the same direction and their angle is 45 degrees or something like that, then just a little traction, with maybe the one hook of the tenaculum, for example. You don't need to get it down to a straight line, but maybe like 120 degrees or something. A slight bend is something an IUD inserter can definitely navigate.
Howard:Yeah, we can put a picture on the Instagram of an ultrasound of a nulligravid uterus with that kind of hyper angle that you're talking about. So patients can, people can see that. But if you're struggling ultrasound is great, by the way, and you can use it to see that angle or even place the IED under ultrasound guidance. If I struggle at all and it feels difficult, I'll often do an ultrasound afterwards just to make sure the placement's correct and I didn't perforate them.
Antonia:Yeah, and I remember early on I was taught in residency to routinely do a bimanual exam beforehand. Maybe that's part of the package insert technique, but the idea was that's one way to tell is there an extreme anteversion or retroflexion or something? And also to tell myself if I sound to something really deep, but on my exam I felt a really small uterus, then I would know that maybe something's not lining up. So I would want this rough size of the uterus that I'm feeling to align with how deep the inserter goes in.
Howard:Right, if you sound an oligravid to 11 centimeters, you may have a problem.
Antonia:Yeah, yeah, yeah, exactly, okay, well, there's. That's our four tips. There's a lot more we could say about it and I'm sure we'll get some mail. Hopefully We'll see. Looking forward to it, as always. Yeah, but let's move on to our next topic, which is talking about some practical tips for student and resident teaching.
Antonia:All of us have had good teachers and not as good teachers in our lives, and it's one of the things that you know it when you have it Is this a good teacher or not as good teachers in our lives? And it's one of the things that you know it when you have it is this a good teacher or not? But it might be hard to define, and when it's hard to define, it's hard to improve. So people go into academic medicine jobs for all kinds of reasons, and not all of them are primarily because they want to teach and that's just their biggest goal in life. Some might have nothing to do with teaching and it's certainly not something that we would get a whole lot, if any, formal education on how to teach. Like, we don't go into this with a master's in education. We go in, we're doctors and then we're just expected to teach rising doctors how we do, what we do, and the traditional medical education has tended to be a mix of textbook studying and then classroom lectures and then basically on the job learning like an apprenticeship kind of thing.
Antonia:So when you wind up with someone who actually has a huge passion for teaching and they're utilizing effective educational strategies and they're a fantastic clinician that you know you can emulate because they do what is evidence-based best practices, then really don't take that for granted, because that's how we wish everyone was and how everyone should be. That's in a teaching role, but it just doesn't always happen. And then, on the flip side of that, probably a lot of the weaker teachers don't necessarily know how poor their quality is of their teaching and that prevents them from ever really being able to improve. So let's see if we can define what makes a good clinical teacher and then try to give some practical advice for anyone who wants to be good or just be better at it. So what would you say makes a good teacher?
Howard:Well, let's go through a list. So great teachers are humble. They don't use their knowledge to make others feel inferior, but rather to inspire them to greatness. And we should realize that your students should and hopefully will surpass you. We were all students one day and we'll all be teachers.
Antonia:Yeah, so it's not exactly inspiring to work with a physician who just uses impossible pimp questions to show off how smart they are, or maybe someone who's always bragging about how great their accomplishments are All right, well, next, great teachers are patient, so every learner makes mistakes, and so did we when we were learning, and you should welcome those missteps as opportunities to teach.
Antonia:Yeah, exactly, Rather than viewing it as an annoyance or rolling our eyes, you talk about mistakes as really being our best learning opportunities.
Antonia:A lot, the whole idea of being a student or resident is being allowed to have the safety of making mistakes and then learning from those mistakes.
Antonia:And I don't mean like letting a first timer just totally flounder in a life or death scenario or something really high stakes where patient safety is at risk. But what I mean is that a lot of the learners mistakes are kept in a protected environment, maybe first in a simulation setting, then as part of a team where there's more oversight from experienced doctors who can step in and correct as needed, keeping the patient safe all the while, and then gradually assessing and giving more appropriate agency and independence, maybe first in low stakes decisions and then onwards and onwards until eventually you have a full fledged doctor. Like that's how we get more doctors and that's how it works. And I think when patients say I don't want any students in my room, sometimes it might be that they don't understand this is how it works, that they think they're just going to be a guinea pig or something. But when a student gets something wrong, that is our chance to assess their knowledge and maybe assess their skill deficiencies and see what needs to improve and then help them improve.
Howard:Yeah, you have to tailor the curriculum to the student.
Antonia:Yeah.
Howard:Okay, well, next, great teachers are kind and they show respect to their students and, contrary to many academic physicians' ideas about teaching, there's no place for shaming or condescension, belittling or any other behavior that serves really only to swell the ego of the bully who's doing it. Students won't respect a person like that. They won't respect you because they fear you. That type of attending or teacher often has their own self-esteem issues and they'll not improve because a student ran away crying and, what's more, they'll forget the lessons, even if they were good lessons. So there's never a reason to not be kind and respectful.
Antonia:Yeah, I think kindness can really make up for a lot. I think that's almost the basis of teaching. And another part of this whole respect is that the student should be a part of the integral care team and they should know that they're an important part of the team, Like they should be introduced to the patients as, like this is part of the team. We need everybody here. They're not just here to sit in the corner past some hours maybe doing questions on their phone while the attendings do all the real work and sigh about whenever they have to stop and attend to the student. Somehow the student needs to be brought in to the patient care Like they're literally paying for this training and if they don't get this training, they're not gonna even be able to be a good doctor one day, and we need them to be a good doctor.
Howard:Well, great teachers have enthusiasm for the subject and learners love passion. If you're not passionate about what you do well, that's a whole different problem. It's a you problem. But be passionate and let students share in your passion.
Antonia:Yeah, it's always nice to work with someone, especially if they have charisma. Some people I don't know if I fit, I'm a little bit more dull probably, but I think I still like what I do, even if I don't always have pep in my step about it. I've been up late feeding the baby or something, but yeah, I don't think students are going to be very interested if you're just complaining every day about every aspect of your job and obviously don't care that person probably should be doing something other than teaching. Yeah, yeah.
Howard:A great teacher show, not just tell. So you know, the traditional tired didactic lecture is ineffective and it's uninspiring, and Generation Y and Z students in particular will lose engagement in less than seven minutes usually. So engagement is crucial and there are a lot of ways of doing that. But you have to engage your students and captivate them, and teaching is 90% showmanship.
Antonia:For that reason, yeah, students definitely don't want to sit in lecture rooms. I don't think anyone ever did at any stage in life and if something can be taught in five minutes, then it needs to be taught in five minutes, not in spread out over an hour or whatever it typically is and whatever the most effective modality is. Of course there's still going to be reading involved. There's just so much material to learn. But when they're in the patient care setting they need to be actively involved in the patient's care.
Howard:Great teachers learn from their students and love learning. So just acknowledging that you can and will learn from your students already makes you a good teacher. How many people deliver the same lecture, period after period, year after year, decade after decade? And unfortunately, too many teachers just tend to phone it in with the same old lecture that they've been delivering for several years. That lecture might have been great a decade ago, but in today's fast-paced and changing world of medicine, it's already out of date. So your students and your patients are being disadvantaged if you don't think fresh each time you deliver a lecture, updating not just your facts but your style. That student who you think is being disrespectful on her phone while you're talking well, she's probably reading the new information, since you're not updating your presentation.
Antonia:Yeah, or doing questions, a question bank or something, because they want to actually learn. And maybe, if you haven't paid attention to being up to date yourself, then, yeah, let them learn in their own way. And obviously, if they don't think what you're saying is valuable and it's not connecting with them and they can see that the new guideline is completely contradicting what you're saying, then they're probably going to take what you say with a big grain of salt. And, yeah, we have to model like we have a responsibility to be up to date and make sure that what we're teaching and practicing is current.
Howard:Great teachers engage their students. We mentioned engagement already, but engagement's about more than just keeping their attention while you teach. Good engagement helps the teacher assess the student's level of knowledge and understanding. It helps a teacher assess the learner's attitude, and then the great teacher can tailor the lesson for the individual student knowing those things. So every student is different, and the best way of teaching each student depends on where they're at in their own development, and engagement is the tool that allows us to discover that.
Antonia:Yeah, I think that's the basis of the Socratic method, like the questioning method, and it's especially powerful with bedside teaching, when you have only one or two students and not a whole crowd. You have to understand what this student needs at this time and the most straightforward way is to ask questions, and that's the actual purpose of what some people might think of as pimping. But pimping is not supposed to be to shame the learner, so it should be to learn where they're at in their education and see where you need to supplement their learning. And, yeah, you need to learn to do it in a conscious way that doesn't shame anyone, especially in a group, for not understanding something.
Howard:Yeah, you'll lose engagement quickly if you're just shaming students. Yeah, now, great teachers have high expectations. To me, this is one of the most important points of all. We do more harm by assuming that students are not exceptional than by any other act. So realize that anything you think that you can do, that 25-year-old person sitting across from you on the couch will know more and do better in their lives, and part of your job as a teacher is helping that student develop her own self-efficacy. You don't do this by being condescending and having low expectations. You do this by showing her that you believe in her ability to understand and do whatever is in front of her. Expect the best from your students and they'll surprise you.
Antonia:Yeah, in general, it seems like the expectations probably are too low in a lot of med schools, and some of that is driven by just the typical multiple choice testing methods that are used. It's not a very high bar for someone to learn how to pass a series of multiple choice questions. We should expect that passing those tests is the very minimum accomplishment, but that itself doesn't prove anything about their competence.
Howard:Yeah, that's just one small part. Great teachers provide a receptive environment and allow mistakes. So if you expect the best and aim high, then, yes, students are going to have failures, but in this, failure again is the greatest of all opportunities to teach the lessons that really matter. Share your own failures with students and they'll respect you even more. You'll teach them the secret lesson of greatness, which is that everyone fails, but the ones who are undeterred by that failure and learn from it are the ones who ultimately succeed in the end. Failure should be our teacher, not our terminus. Great teachers embrace a student's failings with encouragement and nurturing support.
Antonia:Okay, so just to summarize, it seems like the core characteristics from what we've just discussed for a good teacher are humility, concern for the student and their education, staying up to date and educated on what exactly we are teaching, and then all of that is cemented by a passion for teaching and for the subject matter itself. But I think there's a lot of physicians who maybe they've lost that passion or never really had it to begin with, and then they have students or residents, because they're just in a job where it's assigned to them, or maybe they're doing it for that nominal amount of extra money they get, but they're not, they don't have the commitment to teaching that they really should have. So why should? Why? How would you convince someone that they should want to teach, they should teach and they should love it?
Howard:Well, believe it or not, I believe that teaching is actually a selfish act. So, first and foremost, it helps the teacher as much or more than the learner, at least when it's done correctly. So teaching gives you the opportunity to consolidate your knowledge and challenge what you know or what you're learning. If you read something new, teach it to someone the next day. I always tell residents whatever you're learning, go to work and teach your students their questions and the synthetic process of teaching the new information will help you shore up your own understanding and discover any weaknesses you have in your own knowledge base. It doesn't even matter that much if the topic is relevant to what the student needs. At that moment, the student will still appreciate the time you spent teaching and in the process you will model something more important than the facts of the topic, which is a passion for lifelong learning.
Antonia:Yeah, and I agree. That was one reason I've always liked teaching whenever I could. It's one reason we do this podcast, At least for me. It forces me to stay on my toes and stay up to date on literature, and I'm sure at some point, if not already, there's already stuff in our prior podcast that has now been made out of date. But that's just how it goes. But it's just so easy to get set in a routine, learn something, become very competent at it and then never update it, Never challenge yourself to change up your technique at all. I probably like the IUD thing. I don't hold the iodine swabs with the tenaculum and then hold the tenaculum in my hand. That definitely would eliminate a couple of steps from the way I've always done it and just never thought I do this thing in a few minutes. Can I do it in even less minutes? So that's just one example.
Howard:Yeah. So we have to challenge ourselves, and it's a continuous process. We have to continuously learn and incorporate new things and get better, or else we're just stagnant and all of a sudden we're five or 10 years out of training, or 20 years out of training and we're basically everything we do is wrong. Well, teaching gives you the opportunity to discover your knowledge deficit, so if you allow yourself to be challenged by students, they'll show you the limits of your knowledge and your understanding. Students come to the material often with different backgrounds and different understandings, and even teaching the same topics repetitively, but to different students with different backgrounds, will serve to expand your depth with the subject matter. And, of course, this assumes that you're interactively teaching and assessing the knowledge levels and the comprehension of each of your students and tailoring what you teach to their needs. There are some topics that I have easily taught over 500 times, but rarely do I do it the same way twice and you'll benefit from that repetition.
Antonia:Yeah, so people who interact with you might think that you have like a photographic memory or something, but those of us who know you a little bit better will know that you're actually a little bit scattered, but that's okay. When you talk about articles or literature or teach really anything, you're giving a lot of the same talking points that you've done dozens or even hundreds of times, and that's why you have a good recall of it, and residents should appreciate that point as well. So over the four years of an OBGYN residency they'll have many at least dozens of opportunities to teach any given topic to their students over and over again, and they should want to do that so that they can really solidify their expertise in it and be able to recite it offhand. And then, even if something changes in the literature, it's a little bit easier to update that detail than to just never have known it well in the first place.
Howard:Well. Teaching gives you a platform to grow in your knowledge, your eloquence, your understanding and your authority. It's obvious how our knowledge grows through teaching, but you'll also improve in many other ways and these improvements will translate into you being a better doctor. So patients value physicians who speak well and confidently about subject matter that they understand. The average intern has a lot to learn about the medical topics they treat. They average intern has a lot to learn about the medical topics they treat. They have a limited depth of understanding and when they speak to patients they often lack confidence and authority. By authority I mean that the intern is deferential and doesn't believe herself to be ultimately responsible for the patient's care, doesn't speak with confidence and the patient of course senses this and the patient-physician interaction is necessarily limited by that. Yeah, patients of course senses this, and the patient physician interaction is necessarily limited by that.
Antonia:Yeah, patients, of course, appreciate a physician who seems to have confidence and know what they're talking about and be able to explain it in ways that the patient understands, and this, of course, how to do this in the best, most comfortable way possible. It will lead to better patient outcomes because they're going to be, right off the bat, more likely to believe and accept what you say and take your advice and be willing to go along with the treatment plan that you suggest to them, and it'll probably make them less anxious during their IUD insertion, which will reduce their pain.
Howard:Exactly Well, and teaching medical students allows us to grow in confidence and eloquence. Adopting the student's education is our responsibility allows us to grow in authority. If you're a resident, don't assume that someone else will be teaching the students. It's your responsibility. Many residents have poor self-esteem and lack confidence, especially in the intern year, and you'll improve these traits through the act of teaching.
Antonia:A good doctor is naturally a good teacher being a showman, or if you have students that are more introspective and quiet, then that's great, because those qualities of humility and learning from the students and all of that will fit. Those will fit easily and those people will be great active listeners. So emphasize those strengths. What those people will probably need to work on more if they're introverts, is being assertive about their needs so that they get taught their actual knowledge gaps. So be assertive as to what your deficiencies are as well and be assertive about things that you need so you don't burn out. And then they'll probably need help with dealing with aggressive colleagues and patients. That happens to everyone sooner or later.
Howard:Don't want to be run over.
Antonia:Yeah.
Howard:Well, teaching is good for your department and it's good for your specialty. So if you can increase the happiness of your learners through teaching, you'll create a happier, more hospitable and respected rotation department clinical whatever you're doing. And if you can increase the enthusiasm that your students have for your rotation, you'll increase their enthusiasm also for our specialty and in turn you'll attract the best and brightest students to your specialty, which improves the specialty as a whole. My greatest achievement in academic medicine has been to recruit dozens of the best and brightest into my specialty, improving the quality of health care for not just the patients I see but for hundreds of thousands of women in turn, as these students go out in the world and become physicians. And the nice thing about enthusiasm and happiness is that it's reciprocal. So happy and enthusiastic students lead to a happy and enthusiastic you at work.
Antonia:Yeah, so in case people don't know, I was one of your students and there's hundreds of others like me out there and still going on. I was going to go into general surgery because I really loved that rotation and really the whole specialty and I was just envisioning, you know, all the possible different jobs that I could have as a general surgeon way back in med school. And then I rotated on OBGYN, rotated with you, and then slowly realized there's all these great things about OBGYN that I want to be a part of. And then I made the jump and here we are on this podcast.
Howard:And now you're co-host of the most popular OBGYN podcast called Thinking About OBGYN in the World. It's a true statement, okay, well, ultimately, teaching is good for your patients and your community. So our goal is to improve the health and quality of life for our patients and our communities, and you do this by becoming the best doctor you can be, by honing your skills while teaching, and then you apply what you've learned to provide the best, most up-to-date and most compassionate care you can to your patients. And, what's more, through teaching, you'll train a generation of even better doctors to replace you.
Antonia:So all of this was a nice pep talk, inspirational. So what are some practical things people can do to be better teachers?
Howard:Okay, well, number one have some prepared topics that you can talk about at any time and feel comfortable teaching to your learners.
Antonia:Yeah, that's good. So, as a resident, maybe that's three or four different things that you just teach to every single student. You get things that you just teach to every single student you get. They might be, let's say, anywhere from two minutes to 10 to 20 minute prepared talks, and that number of different topics will grow over time, of course, and maybe the subjects can change and evolve as your interests do. But yeah, if you're always prepared to teach something, then yeah.
Howard:But yeah, if you're always prepared to teach something, then yeah, and that could be downtime waiting on a case or sitting in the call room or at lunch or wherever there's opportunities. Ok, well, number two is just to incorporate teaching in that manner into your everyday activities and workflow, whatever that workflow is.
Antonia:Yeah. So if you figure out how you're going to best utilize your students or residents in your normal workflow that was extra hands, extra sets of eyes Think of them as an important part of the job that you're doing, rather than something extra that you're dragging around with you, and then come up with some standard ways that you can use them. You can add teaching into that.
Howard:Okay, well, number three is to have expectations for yourself and your learners. You need to have some goals, and you can make these with your learner by asking them what they expect to learn for the day or the week or the month or the rotation, whatever, and then make sure that that list is adequate, add what needs to be added and make sure you accomplish it.
Antonia:Yeah, and this is important for bedside teaching, maybe more so than for a classroom, because in the classroom you're already going to start a lecture or start a course with that list, but with bedside teaching it can be a lot more variable and depends on what comes across your census, what kind of patients you're seeing, and so the students will realize how important they are in this process If you ask them what do you want to learn, what do you need to learn out of this, and then you deliver on that.
Howard:And it's always better to teach something that people are interested in than something they're not yeah. Number four is to plan activities or educational opportunities ahead of time and schedule them, because otherwise you just won't do them.
Antonia:Right, the clinical realm is just impromptu for the most part. But if you can set aside even a little time, maybe during a lunch break every so often, not overloading them, but just peppering in something, some bit of wisdom, and you have it scheduled, you stay on top of it. Just the tiny bit of structure will improve the experience for everyone, I think.
Howard:All right. Number five is to use materials that you create in advance, that help the student with expectations and then the common teaching topics. So I have a handout. I give my students that on the first day of the rotation. That covers what we do at basic OB visits and things like that, and they can use that as a guide. And, of course, we have a website, obgynstudentcom. Many listeners may not realize that, but that has basic material and learning material on it so that I don't have to go over those basics over and over again the core things that every student needs. I'm also helping with a website like this for students of surgery, which is surgerystudentcom, and that includes a lot of diagnosis scripts for common and high-yield topics and all the foundational knowledge that students should acquire on their own so that the clinical time can be spent with more patient-specific and advanced topics.
Antonia:Yeah, the surgerystudentcom is a really good webpage. I know we're not general surgeons on here, but if you have friends that do teach surgery, then let them know about this have friends that do teach surgery, then let them know about this.
Howard:Well, number six is to create an environment that is receptive to teaching and make sure that your learners have what they need to succeed. So, in practical terms, this means having an office space or setting or place where you can discuss patients privately and do teaching and provide resources that your students may need. That might be recommending websites, like we discussed, or videos or tutorials, as appropriate, that you've curated for them, and in some cases, it may even be getting and lending them textbooks. My students aren't required to have a textbook on their OB-GYN rotation, so I bought textbooks and I lend them to them because I expect them to read them and, you know what, they're more likely to read them because I've taken that step.
Antonia:Yeah, that's nice. There's a couple. There's a couple kind of structured things for preceptors. Let's talk about two of them. So one is the one minute preceptor and then the other one is rhyme R-I-M-E.
Howard:Okay, yes, yeah, the one minute preceptor is a structured method of teaching and it ends up being often more than one minute, but that's okay. I'll put a link to a handout that goes over the technique, and there are plenty of videos and things like that that show how to do this well, if you look for them. But it focuses on five steps, or what they call micro skills, and the first one is to get a commitment from the learner. So, for example, ask what do you think is going on with this patient?
Antonia:Yeah, and that's again the Socratic method, where you need to know what does your student know and then work from that level and if you identify any misunderstandings, then address those.
Howard:Right. And then the second step is to probe for supporting evidence.
Antonia:So, after they've made the commitment, ask them what evidence supports that diagnosis, for example, yeah, and they could be wrong or right, it actually doesn't matter that much but you need to know what their thinking is, what their thought process is, in order to improve their thought process. So if they're wrong, they might just lack facts and knowledge, or they might be making a cognitive error, but either way, this is how you're able to discover that and correct it.
Howard:Exactly. Well then the next step is to reinforce what they did well. So this is especially important if you're getting ready following to remediate something that didn't go so well. But there will always be something that the student did well or something that they picked up on or something that they got right, and you should reinforce that behavior.
Antonia:Yeah, just a little encouragement so they don't throw the whole baby out with the bathwater, kind of thing.
Howard:And also so they keep doing what they've done well.
Antonia:Yeah.
Howard:And then step four then, of course, is to give guidance about those errors or omissions that they might have made. So this is where you now take what you've learned about their thought process and what their understanding is, and you point out what they might have missed or misunderstood or what they just don't know, and this is where the real teaching happens, at least for that patient.
Antonia:Yeah, and you can do this in a way that it's not received negatively, because people will shut down if they feel like they're just being criticized.
Howard:And so this relates back to all the other things we've been saying here about the teacher's attitude, about celebrating failures for the fantastic teaching opportunities that they are and building people up rather than tearing them down discussion will be reminded of a general principle from the particular patient problem and I'll focus more on teaching that in more detail and not only will it help with that particular patient or case, but it will help them with all other patients and cases that are related.
Antonia:Yeah, and you probably don't have to be married to all of these steps in order to utilize this one-minute preceptor system, but if you are struggling with engagement in teaching, then this method will work pretty well and, for residents and new teachers in particular, doing this a few times a day will make it a very accessible and productive habit. Okay, so next one, the rhyme R-I-M-E. Go into that one.
Howard:Well, sure, and I'll put a link to this as well, but this is a framework for understanding how students develop in their cognitive skill set and you can use this to monitor their progress or, in some cases, even give grades or do evaluations.
Howard:So the R stands for reporter, and this relates to the initial skill of gathering information and reporting it back. The I stands for interpreter, and this relates to how well they're able to develop differential diagnoses and use the information they've gathered in an effective way through the diagnostic process. The M stands for manager, and this relates to how well they're able to develop a treatment plan. And the E stands for educator, and educators are able to teach their colleagues and perhaps just as importantly, the patient about the diagnosis and the treatment plan, and you'll see students develop if you're looking for it over this pathway and be at various levels of cognitive development. I actually try to explain this to my students on initial parts of their rotations to help set expectations of what I want to see happen in their development and treatment of patients and, over time, hopefully see that, and also to just accentuate the point that being an educator is the most important and final step of being a good physician.
Antonia:Well, that's a nice little ending point, then, perhaps because the best physicians are the best teachers or educators, isn't it that the word doctor means teacher, if you look at the word root, it does indeed. Yeah. So there's a ton more we can say about all these topics, but we still wanted to have this historical tidbit. I think, if we have time, Do we have a few minutes to talk about blood transfusion.
Howard:We'll do the big parts.
Antonia:All right, we'll take it away.
Howard:Well, blood transfusions, of course, are an essential component of modern medical care, and obstetrics in particular. So hemorrhage in the past was one of the leading causes of death during childbirth, and many things have contributed to almost eliminating death from hemorrhage, at least in developed countries. But blood transfusion, of course, is an integral part of that. There are some practical limitations and things you need for intravenous transfusions of blood, just like having needles or tubes or something to draw off blood and insert it back in and to facilitate that transfer. And then, of course, there's knowledge limitations that you need, like understanding the circulation system and, of course, maybe even more importantly, the compatibility of blood between people. And all of these things proceeded through history through different developmental routes which we don't have time to discuss today. But by the 17th century people were experimenting with transfusions in animals and eventually from animals to humans. So in 1667, a French physician called Jean-Baptiste Denis transfused sheep blood into a 15-year-old boy and another patient, who both lived, but apparently only a very small amount of blood was given. And when he tried it a third time, perhaps with more blood, the patient died, probably because that larger volume caused an allergic reaction, we would assume. But building on this work. A British physician named Richard Lauer developed much of the necessary apparatus to perform blood transfusions and studied the circulation system in detail and performed many animal-to-animal transfusions and eventually an animal-to-human transfusion in London. But the French government and the Vatican, for reasons you can only imagine, banned these transfusions, particularly from animal-to-human blood, and so nothing really happened for another 150 years or so, even though most of the tools were in place.
Howard:But in the early 19th century there was a British obstetrician named James Blundell and he was interested in using transfusion to treat hemorrhage. Now, the previous transfusions weren't actually done for hemorrhage, but they thought that they could use sheep's blood to calm people with psychiatric disorders because it was felt that the temperament of the animal was transferred through the blood and I guess ewes were thought to be peaceful. I don't know, but Blundell was interested in saving lives related to postpartum hemorrhage. And finally, in 1818, after he had experimented himself with animals to test the equipment and the ideas and the practical aspects, he had a patient who needed blood and he transfused some of the blood of the husband into the woman during a postpartum hemorrhage and she survived. And then over the next several years he had many, many more successful transfusions that proved to be life-saving and beneficial and in fact, the techniques and the equipment that he developed at the time made him a millionaire even back then. This is millionaire in 1820 dollars.
Antonia:It's interesting because now things are coming back to whole blood transfusion as being superior to component, but I guess they missed the whole thing about blood types at the time.
Howard:Yeah, no, the idea of the AB and O blood groups wasn't discovered until 1901 by an Austrian named Karl Landsteiner, and that was a major breakthrough. That obviously was a real critical piece. We needed to make transfusion safer. Most of the early complications of transfusion were due to incompatibility, and blood transfusion didn't become common until after this discovery. And Landsteiner went on to win the Nobel Prize in Physiology and Medicine in 1930 for that discovery.
Antonia:All right, so another important life-saving breakthrough that was discovered by an obstetrician. How about that?
Howard:Well, we can't give him all the credit, just most of it. But he had the courage to apply the technique because he was tired of seeing women die of postpartum hemorrhage. Now I will say, since we've been talking about surgeons, the first successful blood transfusion in the United States was done by the famous surgeon William Halstead In 1881, he was visiting the home of his pregnant sister who had the baby while he was there, and she had a postpartum hemorrhage after she gave birth, and he tapped into his own veins and infused some of his blood into hers to save her life. And so we think this is the first successful blood transfusion in the United States.
Antonia:Well, he may have been a surgeon, but that still counts as an obstetric case.
Howard:Still an obstetric case? Yep, fair enough.
Antonia:Okay, Well, I think we should wrap up for the day the Thinking About OBGYN website. We'll have links to stuff we talked about and we'll be back in a couple of weeks about.
Announcer:OBGYN website. We'll have links to stuff we talked about and we'll be back in a couple of weeks. Thanks for listening. Find us online at thinkingaboutobgyncom. Be sure to subscribe. Look for new episodes every two weeks.