Leaders in Medical Education

Dr. Dustyn Williams, Founder and Lead Educator of OnlineMedEd

Osmosis Team
Jul 21, 2016

Dustyn Williams completed his undergrad at Yale and his med school at Tulane University School of Medicine. He's a board-certified Internal Medicine hospitalist at Baton Rouge General where he is the Clerkship Director for Tulane students in the LEAD curriculum and Core Faculty for the Baton Rouge General Internal Medicine Residency Program. He is a published author and is the co-founder of DoseDr, a diabetes management telemedicine platform. Williams is also the founder and lead educator of OnlineMedEd, which is designed to help third and fourth-year medical students learn the foundation for their careers.

How did you first become interested in Medical Education?
See one, do one, teach one. That’s what I began with in my residency application personal statement. And for me it was true. I’ve always had the passion to figure something out and then help others learn it. I did it with bartending in college (I created a bartending class for seniors in my dorm), with EMS right after college (I was a paramedic who helped teach the EMT-Basic course), and in medical school.

Post-Katrina New Orleans was something most people cannot fathom. Most of the city was still dark – no power at all. While Tulane had power, it lost a substantial amount of its faculty. We had histology labs with no PhD; students were left to fend for themselves with a rack of slides and some 50-year-old microscopes. Oh, but we had Smart Boards in every room, so that was dope! What ended up happening was that I would listen to my instructor (who was awesome), then I’d put a little thing together, and I’d host it for people in my class. I was a member of the “Owl Club” (the student organization for academic excellence) so I guess I had clout. Maybe. People showed up and used my stuff - my fellow classmates were clearly desperate for something better than they were getting. Let me reiterate – I was at the same point in my training as they were, yet they were using me to get ahead.

I ran the Note Service - students taking notes for other students, got Tulane to sign up for Tegrity (video recording of PowerPoint presentations), and was part of the team that first designed the Tulane Med intranet (it was totally student-made the year it was released). I kept trying to find answers to the question, “what would make this process better?”

But the switch really flipped one fateful day during Ob/Gyn. If you read the introduction to the Intern Guide, you’ll get more detail. We spent 2 hours (TWO HOURS) on the differences between estrogen and progesterone in each oral contraceptive pill. The answer on the test was “OCPs.” Right then I made the commitment.

I knew I could do this better. I had mentors who were champions of medical education. I got myself some formal education in teaching 4th year of med school and I got to practicing.

Can you share your background on how you got to where you are right now with OnlineMedEd.org?
OnlineMedEd was forged out of my frustration with the medical education system. I learned more from external resources than I did from medical school (except internal medicine, which is why it’s the field I chose). So I borrowed a camera from a guy who works at the superdome (thanks, Paul), got some lights, and started filming. I converted a bedroom into a studio and convinced my girlfriend to work the camera. She literally fell asleep during one of my lectures.

The quality was abysmal: the videos themselves were 320p, the lecturing was shockingly poor, and the information I was expounding was factually mediocre. Holy shit was it harder than I thought. I didn’t know how to use video editing software, how to light a white board, and I didn’t know how to teach. But practice makes perfect – spending 8 hours per lecture x 225 x 3 iterations has helped. So too was “hiring” my dad to fly down during my residency vacation time to spend 80 hours a week filming (his salary was time with me).

It was just a hobby initially – medicine came first. But people found them, watched them. Then I made a crappy website, then someone made me a better one. I didn’t advertise or market myself, but people found this free website. It began to grow, but glacially.

Enter Jamie. He saw the potential and wanted to blow it out. It became his project – it would have taken me a decade if not properly motivated. Jamie turned it into a company with greater ambition than I had ever dreamed. When he started in late 2013, we didn’t know what we were doing. We got some money from our families and hired a developer based on a favor Jamie had from undergrad. Long story short, he had the same heroin dealer as Phillip Seymour Hoffman. You should ask Jamie… good story. While I was busy writing additional content (usually “not” in the hospital after 30 hours) he was busy wrangling our contractors.

We finally launched the platform in Nov 2014. We were late, out of money, and out of patience. But, boom – I remember watching the Google Analytics and watching the session numbers double, quadruple, and eventually 10x. By Nov 2015 we had 35,000 active users a month. By active I mean “on the site using it for free”.

But that’s ok – we’re doing this for the betterment of mankind. Sure we want to be successful and make money, but it’s more about undermining the predatory nature of corporate education (no names, but the ones prey on fear and charge 3000 dollars for 3 months of content so you think you’re safe). Even higher, it’s about lowering the barrier to quality education – if you have the internet you now have free access to a standardized foundation of knowledge.

We’ve survived and made it to the second iteration of our site. We’re constantly refreshing the content. We’ve brought on peer reviewers (most of them volunteers). We gave, so others give back. We’re up to 45,000+ unique sessions last month with over 2.2 million minutes of active lecture viewing. We’re partnering to bring in physical diagnosis, international medicine, public health, step 1 material, and more. It’s exciting.

Can you talk about your learning system – how did you come to the methodology behind it?  What challenges, if any, do you believe still remain for the implementation of your ideal online medical education resource?
There are a few ways to answer this. I’ll start by saying what separates us is we are actual content creators. Some companies write content, others take what’s out there and apply new technology to it. We’re doing both. The key is to understand what it takes to be effective. It means giving the learner the tools to make the right choice when there isn’t anyone else to ask, whether on a real person or on a test.

Most teachers teach what they want to teach in the way they want to teach it. That’s different from what a student needs to be successful. My teaching isn’t about what I think is important, nor is it about knowing everything – it’s about being effective. Part of that includes my #1 philosophy – understanding is more important than the truth.

At the core is my organizational strategy, which is just how I learned. Keep the foundation strong, use good organization, and recognize that you can always look up details that might be forgotten. That’s why OnlineMedEd seems so simple. Don’t memorize – use methods.

Teaching at a white board comes from my mentors. The pedagogy is mostly based on the UCSF style of medical education. The two people who influenced me the most were Jeff Wiese (Tulane IM director) and Chad Miller (Tulane IM clerkship director, now a dean at Wash U). I learned from them and was given the venue to practice and get better. So the pattern goes - much like the succession of the Dread Pirate Roberts - I put on the black mask and take up the task where they left off.

Enter the tech and methodology that builds on my teaching strategies. The curriculum is designed to be self-directed with the ability to be customized to any learning preference. It captures all VARK learning styles. Research demonstrates early everyone is a little bit of each one; by engaging in multiple styles simultaneously you enhance understanding and retention. We use the PACE paradigm: Prime (notes), Acquire (videos), Challenge (qbank and cases), and Enforce (as in reinforce, with flashcards and QuickTables). The site tracks it all and allows for timed repetition, which helps make it all stick. The strategy’s developed through primary literature and is being used in real research across the country.

As for challenges remaining - PACE is great, but Online Medical School can’t be a thing. I can improve retention and understanding of medical knowledge. But it is the integration with purposeful practice – both with virtual patients in the way of cases as well as experiential training with real people – that will make it exceptional. WE can improve the website, make the database more robust, what have you. But those are tweaks. The ideal online platform needs to be integrated with institutions of higher learning. It can’t be a thing students use on the side that lets them succeed in spite of medical schools, but rather something the schools integrate into the curriculum to help the students succeed because of medical school.

Your platform is an online one.  What are some changes in the classroom you would like to see in the current medical education system?
Flip the Clerkship. There is so much talk about flipping the classroom. Khan Academy! Coursera! But then no one does it. I actually attended a session at SGIM where the guy, who had successfully done flipped course in ECG, was lamenting about how hard it was to make, how much time it took, how unstable the servers are, or how restrictive the university firewalls are.

Wouldn’t it be awesome if someone had a stable server, a website that anyone could access from anywhere in the world, and all the hard work was already done? Oh… wait… we did that already.

I’ve done it with the Tulane Curriculum at Baton Rouge. Students use OnlineMedEd to review an organ system a week. They get weekly didactic sessions doing cases together. They walk in knowing the fundamentals (what I teach in the course) and then I make them go to the next level. It requires they use reference texts, cooperate with each other, and act as a team. It’s awesome - 3rd year medical students starting talking like PGY-1 interns.

We have to get away from hour long slots in dark rooms with PowerPoint presentations. It is an impossibility that everyone is mentally ready to start when the professor is. That’s why you see classmates playing Clash of Clans or checking their email. What did he say? Meh, let’s check the game. Auburn’s up by 7!

I’d like to see the teacher assume the role of the discussant. Instead of lecturing, guide teams of learners through cases that build on fundamentals they can get elsewhere (like OnlineMedEd). Show them the path rather than hold their hand down the road.  This is hard as it’s a paradigm shift for teachers. And since no one teaches the teachers how to teach, they’ll likely keep doing what everyone else did to them – give the same PowerPoint lecture to every group of students in every block exactly the same way.

How do you think technology has come to play a role in medical school in the present and how will it help shape the future of medical education? What problems in medical education do you think technology can help fix?
Traditionally medical schools have taught medical knowledge. These days being a doctor is far more than just knowing a bunch of stuff. Medical training has always been experiential (that’s what residency is for). But more than ever before there is emphasis on teamwork, communication, patient safety, and personally connecting. Oh, and we’ve increased what we know about medicine exponentially over the past two decades.

You can’t truly lecture somebody how to have a decent hospice talk, how to extract information from a patient in the ED, or how to run a morning huddle on the floor. Those things have to observed and experienced to make an impact. That takes a lot of time.

Technology liberates time. OnlineMedEd is a perfect example. You don’t need lectures -  we have that part covered. It teaches efficiently and effectively at the level of the learner. Then they can go actually practice medicine.

Both the delivery of information as well as feedback and evaluation can be made more convenient. The SP center is only open from 12-5? Well, that’s when you have to do your training, your practice, your eval, and the teacher needs to be there the whole time. I’ve also done a few projects using technology and practical education. Students record spoken H&Ps and then evaluate each other. Students watch videos on the physical exam, then practice in front of each other.

Lifelong learner.  What does that mean to you? What advice do you have to help medical students faced with a firehose of information break the cycle of learning and forgetting that often accompanies test taking throughout our educational system?
Methods and perfect practice.

Skills decline is a natural phenomenon. You study REALLY hard for Step 1. A year later, you don’t even remember what 2,3-UDP-glucoronyltransferase is (or how to spell it). But you know you knew it. This will happen in every phase of life, from knowledge to physical skills (I use to be a national level butterfly swimmer - now I’m more of a dying orca than a swimmer). As you peak in your training (generally residency) you know the most, you do it the best, and you achieve. Then you start to practice. You take shortcuts and don’t keep up with literature. You don’t even know you do it, but you do – everyone does.

The first thing to realize is that the higher you make it during your peak, the better you will be for life. It is not practice that makes perfect - it is perfect practice. Practicing swinging a golf club in preparation for tennis isn’t going to make you a better tennis player (or a golfer). So too is it for your mental fitness. Train the right way.

Then mitigate skills decline by constructing methods. They can be algorithms, an acronym, a picture, whatever advanced organizer you want. Engage that organizer over and over again. Come back to it as your illness scripts become more robust, as you have more variations of the thing you practice. Because this heart failure isn’t that heart failure; no two gallbladders are the same. But the cholecystectomy you’re doing right now shares a lot in common with the other 100 you trained on. This patient right here is not identical to the last one with heart failure, but you can fall back on the methods to figure out what to do with this person in front of you.

The problem is that students now believe (because its worked so far in their career) that “knowledge bulimia” is effective. Cram it all in there, regurgitate immediately after the test, and repeat. This style of learning is about survival. That’s all that happens - you survive. You don’t become a master of the craft or a leader – you just survive. Students keep thinking “if I just get through this next part… then I can really start learning.” Except when they get there they have no foundation to build on. So, overwhelmed with more information, they revert to what they trained to do their whole life – knowledge bulimia.

I won most knowledge resident of the year twice in residency. I am looked up to as this knowledge guru. And I don’t say this to brag. I say it to prove a point. Because it’s all a lie. Yeah, I work hard. Yes, I keep up with reading. But why I LOOK so smart is because I have methods. And that’s what I teach onto others.

Do you have any final thoughts on the medical profession or healthcare system as a whole?
I’m not supposed to say it, but I rather preferred the paternalistic side of medicine. The indigent population who didn’t have enough education to understand what was happening but was diligent enough to do what they were told. And there was this inherent trust people had in their health care providers.

I’ve seen an erosion of that trust. The fallibility of physicians has been widespread across the nation (as it turns out, doctors are people too). The push towards “patient satisfaction” and “federal quality indicators” is garbage. We’re letting the businessmen and bureaucrats dictate how medicine works. And when we give up a decade of our lives with the sole purpose of helping people, we find ourselves trapped in this rat maze of 4-page-long epic notes and 10 times the number of back-end people as front-end, just to keep the business going. And most of my time is spent explaining why a 10 minute degree from webMD isn’t as good as a real MD. Or worse, 20 minutes talking to the patient’s husband about his deer stand to improve my quality metrics. Times are changing, and there’s a lot to still figure out.