How to Study Better and Reduce Burnout - Dr. Jason Ryan, CEO of Boards and Beyond

DR. RISHI DESAI: Hi, I'm Rishi Desai and today on Raise the Line, I'm happy to be joined by Dr. Jason Ryan. Dr. Ryan is a practicing cardiologist who received his MD and MPH degrees at the University of Connecticut School of Medicine in 2001. He's been a practicing cardiologist since 2008. He's also a faculty member at the UConn School of Medicine and is the founder and CEO of Boards and Beyond. Thank you so much for being with us today. 

DR. JASON RYAN: Thanks for having me. 

DR. DESAI: So Jason, I was just noting that you're a lifer at UConn, a Husky. I'm just curious, do you mind just telling me a little bit about your background and what got you first interested in healthcare?

DR. RYAN: Yes, sure. So I'm from a town called Trumbull, Connecticut, and I went to college in Pennsylvania at a school called Lehigh and I studied chemical engineering there. I actually had no inkling of ever being in healthcare. In fact, there were a lot of pre-meds in some of my classes like organic chemistry and they sometimes drove me nuts because they were obsessed with getting the perfect grade on everything to get into med school. However, after I graduated, I worked for a year for an engineering company and I sort of could see the path ahead of me. It was a cubicle kind of job, it wasn't that exciting, and so, I started to reconsider my options. I had some friends who were in med school who were liking it and I did some shadowing, and so long story short, I applied to med school and went to medical school at the University of Connecticut. That's how I got into it; it was kind of a second choice, not the first thing I was going to do.

DR. DESAI: Do you feel like your background kind of starting outside of medicine has influenced your journey at all?

DR. RYAN: Yes, I do. I think it helped a lot. For starters, I still have that sort of engineering mind of fluid flowing through a pipe and things like that, and what little math there is in medicine never really bothered me. It also helped a lot that I worked for a year and I saw a lot of people miserable in their jobs so when medicine got hard, I never sort of said "Gee maybe there's this rosy great place out there where I could have a real job" and I was always so glad to be in medicine and felt like I was better off.

DR. DESAI: Jason, you started Boards and Beyond, which is a platform that helps a lot of medical students prepare for board exams. How did you come up with the idea to start that company? 

DR. RYAN: Yes, great question. I came to UConn in 2008. I was on the faculty as a cardiologist, but I also taught the medical students. They liked my teaching and they told me they liked my lectures and I got some awards, and then one of my students who came to my clinic showed me Pathoma and he said, “This is where I'm learning everything I learn from now.” I thought it was a freaking amazing thing. It was such a cool idea. 

You may or may not know that in med school, there's only a limited amount of teaching you can do. There's a lot of faculty who have been in certain teaching roles for years, so I was this young eager faculty who wanted to teach more, but there was only so much I could do. The idea of making videos felt like freeing; I could teach whatever I wanted. So that was where I got the idea. I started looking into it, and you know this as well as I do that websites that stream videos behind a paywall are not cheap to build. There was sticker shock at realizing how complicated it would be to do something like this, but I have a lot of support from my family, and we invested a bunch of money to build a website. It took a long time for people to start using it. For at least a year or two, I was just giving it away for free until people started to catch on and it started to become a thing. 

DR. DESAI: What are your learnings during that time? Let's say from the start of the build-out to the point where it started becoming a huge, huge driving force in the space. What are the big things you learned along the way that maybe you didn't know when you embarked on the journey? 

DR. RYAN: One of the biggest things I learned is, at least in this business of medical students, people only want to use something that the class before them used and says is worthwhile. So you can have the flashiest website and coolest ad campaign, but it's not going to get much traction until really some years of students have used it and are telling the class behind them, "Okay, I used this; it helped me a lot." It's really a word-of-mouth business more than anything I can think of.

DR. DESAI: With that in mind, I'm just curious, what are your plans as you go forward with Boards and Beyond? What are the areas that you want to grow and develop? 

DR. RYAN: So we have a full library of step-one content with an associated question bank. The way I always learned is like, when I go to a conference, somebody will give a lecture on let's say echocardiography. At the end of the lecture, they'll have five questions that they go through, and the audience votes. I've always found that to be the most effective way to learn. You get content explained to you by an expert, and then you get to put it into practice yourself. So that's always been the idea of Boards and Beyond is a short lecture by video and then four to five questions to test yourself and make sure you've got the information. We have that for Step 1, and now we're building it for the Step 2–3 content, which is more clinical. It's probably about 80 percent of the way done for Step 2. Our goal is to finish that by the end of this year. 

DR. DESAI: That's awesome. There are lots of different phrases for that, like flipped classroom or blended classroom or what have you, but I'm curious, as you do more and more of this, have you gotten feedback from faculty, and if so, what are their thoughts on applying it the way you just described? 

DR. RYAN: Faculty are a funny group because a lot of faculty feel like, “I can teach this stuff myself,” and they feel like students don't need to go to resources like Osmosis or Boards and Beyond, even though a lot of students don't agree with that and they feel they need some help from somebody outside. I think faculty are coming around to the flipped classroom side of things. It's getting harder and harder to recruit faculty to teach because the demands for clinical medicine are so great that I think more and more schools are asking their faculty to record a video that the students can watch. That's slowly replacing the in-person teaching, which is just getting harder and harder to coordinate when faculty have patients to take care of. So I think it's coming along; we definitely have some institutional partners who like our videos and buy them for their students. I think a lot of other schools are still making their own content as well. 

DR. DESAI: What recommendations do you offer to schools that say, "Hey, how do we best incorporate this into what we're already doing? Can we train our faculty to do these kinds of videos for their students just like you do?"

DR. RYAN: It's a good question. No one's ever asked me to train anyone how to make a video. I'd be glad to do that, but no one ever really has. I think the schools that have bought it are schools that basically have enough funding to support their students. They know all their students are going to buy it anyway, so they've sort of bought it to help them along. Then there are a few schools where a faculty member will be running a class on, say, heart failure, and they'll assign the videos for students to give them an orientation before they come to class and will maybe do an exercise together to learn more about it. 

DR. DESAI: What sort of advice do you give to students, then, that say, “Hey, I do need to learn this—not just for my exam, but maybe when I'm a cardiologist one day. How do I retain this information that I'm getting from the video or answer the questions? How do I best study for exams, but also remember it years down the road?”

DR. RYAN: I love to tell the story to my students of when I took the cardiology echocardiography boards, and about a month after the test, I found one of my review books in my car under the cushion, and I took it out and I opened it to a page, and there's a lot of physics equations on the echocardiography board about sound waves and things like that, and I had circled and starred this one equation. I could swear to the life of me, I'd never seen it before in my life, even though I had circled it and started a month earlier. So I tell that story to remind students that information that you don't use regularly, you will quickly forget, no matter what it is. There are things in my own videos, but I made the video two years ago, and a student will come up and ask me, and I'll say, "What? Wait for a second, you've got to give me a minute to reorient myself because I don't have the names of every single artery in the brain stem at my fingertips. That's not something I do every day." 

So if you accept that reality that you're going to mostly remember what you use every day, then it really helps you to build your study plan, because let's say you're six months out. There's no point in memorizing all these little fine granular details; they're just going to spill out of your brain. That's when you need to make sure you understand the big picture: How do these drugs work? How does this disease work? Then the month before your test is really a critical time; that's where you can memorize these things and they will stay in your brain so that you'll have them at your fingertips. 

One of my students said to me, “I feel like, Dr. Ryan, I get stupider every day after Step 1,” because these facts just leave her brain that she had crammed in there. So accept that reality of the time-limited nature of fine granular details that you don't use every day, and then build your study plan around that.

DR. DESAI: It's funny you say that. I took a picture of myself the day of Step 1 just so I would know what I looked like on the day that had the most information in my head.

DR. RYAN: Right. Smartest you'll ever be, right there it is. 

DR. DESAI: Yes. It's been a long downhill ever since then.

DR. RYAN: Of course.

DR. DESAI: So in terms of this framework of, there's a lot of information you just don't use every day, I'm just curious—What if now, you were advising NBME or these other test makers. What thoughts do you have from that standpoint? Do you believe these tests, as structured today, are serving the function that they need to? Or do you feel like there are some tweaks or changes or modifications you would recommend to be made? 

DR. RYAN: Yes. If I were a king for a day, I would immediately make these tests open book, because that's the reality of the world we practice in. My grandmother was actually a physician, she graduated in 1940 from medical school and when I was a little kid she would practice medicine and she had all these books on her shelves and so if she didn't know a fact immediately, there was no way she could easily look it up. She would have to go to a library. So in her age, you had to have information immediately at your fingertips: names of drugs, diagnoses, tests you were going to order. 

This is a totally new world now, but we're still testing like we practice in that world. In the current world, the best doctor may not know the second-line antibiotic for some rare infection, but is super skilled at looking that information up quickly because he or she has a framework for what they're trying to do for the patient and knows how to access the information. That's what we should be testing, because then you would really get at mimicking clinical care. 

When you have a patient, you have a limited amount of time to deal with that patient: 10–15 minutes, whatever. Can you quickly look up what you need to look up and not have it memorized at your fingertips? I've met a few people who are involved in board writing and ask them this question, and it doesn't seem like this is on the horizon, but boy, I wish it would be, because I think that would mimic the reality of the world we practice in.

DR. DESAI: Yes, very, very similar thoughts. I've always felt like open book makes 100 percent sense. If you want the test to proxy reality, then proxy reality.

DR. RYAN: Right. Agreed. You can't look things up for hours; you'll never finish the test. So it also tests your ability to triage the information and not get down in the weeds. It really would be great if that ever happened. 

DR. DESAI: Yes, I couldn't agree more. I'm curious, what are your bits of advice for folks that are now thinking about, “I'm a practicing physician, more and more CME is happening at my fingertips. MOC, Maintenance of Certification is happening, with these kinds of quarterly assessments.” Do you have any thoughts on that? Do you feel like that's a move in the right direction, where it's happening on more frequent intervals versus these long five–ten-year cycles? 

DR. RYAN: That's a tough question to answer. I dread recertification exams. On the one hand, there is some value to pausing from being in the trenches and going back to the books and refreshing your memory on some of the basics. On the other hand, it's really hard to find time to do that with the demands that are placed on us for patient care. So while I appreciate them trying to break it up into smaller bits and pieces, having to constantly be re-certifying every four months or six months is a real burden on people. Also, these exams are very expensive and the amount of money we have to sink into them is usually not covered by our employers. I think it's a thing that makes physicians feel like we don't matter, like we're not that important.  They wouldn't treat people they respected by making them pay $3,000 every couple of years and sit for an eight-hour exam. I really wish they'd find a better way to allow you to document that you're keeping yourself up to date without having to pay so much money for these exams. 

DR. DESAI: Going back to what you said earlier about being king for a day. Let's say that you had two days—you've already done the first day, now, you're on your second day, and you can fix this system. Is there another profession that you look at and you think, “Gosh, they've got it figured out.” Maybe it's folks that are pilots or other industries—Do you feel like there's any sort of solution here that would make the person feel respected, but also accomplish this idea of keeping people up to date on information?

DR. RYAN: If you could create very popular CME and just make it mandatory, that would be really nice. What's popular for one person may not be the same for another person, but most doctors I know don't mind keeping current and attending grand rounds and learning about new treatments and doing some form of CME. So I think the way it's delivered is not always the most effective way. It's hard for people to get the CME credits they need, but that seems to me to be the way to do it is to just say, “You must keep up to date in your field, and these are the ways that you can do it. Some of them are going to be enjoyable and not too difficult for you to do.”

DR. DESAI: Switching gears a bit, but also kind of thinking about the healthcare system broadly, COVID-19 is still here and things obviously got a lot better in the last week, in the US at least, but it's still here and I think we realized a lot of broken elements of our healthcare system, maybe we knew about them before but kind of brought it to the fore and certainly the general public is more aware of them. What do you feel are some steps that we ought to be thinking about and taking to strengthen our healthcare system on a broader level?

DR. RYAN: That's a good question. That's a big question. I wish I had an easy answer for that. I will tell you that I worry a lot, because the students I advise and talk to are already showing what I consider signs of burnout by first or second-year, things that I had seen in more advanced trainees after a long week of call, and they're already appearing to be burned out by the second year. I think we're at risk of creating a generation of burned-out doctors if they're already coming out of second-year med school feeling like this is overwhelming.

I spend a lot of time trying to just normalize things for med students. I don't think it's told enough that it's supposed to be hard, I think a lot of students feel like they're the only ones that are struggling and everyone else has it easy. I try to spend a lot of time letting people know how normal it is to find this to be a difficult process. For us, as educators, anything we can do to peel back mandatory onerous requirements out of a thought of trying to make burnout less frequent, is worth doing. We're not training marine recruits, and we don't need that type of atmosphere.  The more we can treat people like adults and give them freedom, and try to take away some of the onerous things that they're required to do, the better it is.

DR. DESAI: Are there some examples of onerous tasks that you see either house staff or attendings having to do, that you wish, “Gosh, this has such a little value in the real world and the burden is so great—let's just get rid of this thing.”

DR. RYAN: Well, I can only speak for myself, but when I give a conference, I feel like, if you don't want to be there, you shouldn't come. I mean, you're an adult, you're a learner, you're going to be a physician one day. You're going to have to know something about EKGs or whatever I'm talking about in that particular day. But I don't like having students in the classroom that are forced to be there. I did some graduate work between undergrad and med school, and in a lot of graduate schools, attendance is not mandatory. This is the way I think a lot of other graduate students are taught. So my feeling is that the fewer mandatory things we have, the better. Now, if you don't show up for anything, then you're going to pay a price when it comes to your grade, or your assessment, or things like that. So it's not like you can just coast through medical school, but I personally don't like mandatory lectures very much. 

DR. DESAI: I always thought it would be interesting to have, instead of paying tuition all at once—Let's say the tuition is $30,000 or $36,000. I always thought it'd be cool to kind of split it out by lecture. You'd have to walk to the front of the class and hand a hundred dollar note over and then go sit down, and then it would make each lecture really remind you, like, was that worth hundred dollars or was it not?

DR. RYAN: It's true. It's totally true, but unfortunately, at medical schools, you can make a real name for yourself if you build a huge clinic taking care of surgical patients, or something like that, but if you have the most highly attended lectures by the med students, it carries a much smaller amount of credibility in terms of your career. I think med students feel that, because they can see, where are faculty putting their attention? Oh, they're operating all day, they're reading imaging studies all day, they're doing something other than teaching me, because that's what's valued. I think this also contributes to the feeling of burnout. 

DR. DESAI: So we're a teaching company, as is Boards and Beyond, and I'd love to learn about some knowledge gap. Maybe it's something about cardiology or something about your experience in running a company—any sort of myth that you want to break for us, or any gap that you commonly have to explain to people over and over again that you might be able to clear up for me personally, or for our audience, would be very appreciated. 

DR. RYAN: The biggest gap I see is people taking care of patients by a recipe or an algorithm without understanding where the data comes from. To give you an example from my field, in cardiology, we prescribe ACE inhibitors for heart failure. They're one of the main drugs we use to treat them. Well, the reason we prescribe those drugs is because there were a number of clinical trials that showed very specific benefits in very specific groups to patients with heart failure. I wish more people understood that, instead of just saying, “Heart failure equals ACE inhibitor,” because it has huge importance when you're taking care of patients. Certain patients, older patients, certain comorbidities, they weren't in any of those trials of ACE inhibitors. They've never been studied; we don't know if the drugs benefit that group. So we'll still use them in that group, but if there's a reason where the drug might carry a risk, that's a group that doesn't need to take that medication.

This is true for everything we do. Every antibiotic is based on certain data; every imaging study is based on certain data. The one thing I spend the most time with trainees doing, is talking about, “How do you know that treatments going to help that patient? How do you know it's going to work? How do you know the risks of an adverse outcome are smaller than the risks of a benefit for this particular patient?” I think because we start by teaching mechanisms early on in med school, we imply all these treatments must work because they have the mechanism and it's plausible. It's only when you get to a higher level that you start to understand the evidence behind them, and the caveats, and the groups they work in and they don't work in, and so that is sort of my biggest peeve or fear in medicine is I don't like to see trainees become these sort of cookbook practitioners who just reflexively say, “This is the right answer; you need to get it.” I want them to understand what the data is that that right answer comes from, so that they can tweak it to the particular patient or dealing with.

DR. DESAI: Now, I guess a challenge that I've always felt myself, and I'd like to know how you deal with this challenge, is that the amount of data is overwhelming. In the last twelve months, for example, with a single infectious disease, COVID-19, it is bewildering how many papers have come out. If I'm an ID doctor—I do pediatric ID—then I don't get the privilege of just having to deal with one infection. There are many, many other ones that I have to stay on top of, to some degree.  How do you, personally, stay on top of the new literature that comes out on the latest and greatest treatments for heart failure? What is your own practice to stay on top of it? 

DR. RYAN: One problem is the new latest and greatest research, but another problem is just knowing the tried-and-true research, too. Especially in cardiology, there's always a fancy new medication. It's usually very expensive, not generic, and it has a positive trial. I'm always very dubious of those types of interventions until it's been around for a while. Especially, it used to be to get FDA approval, you had to have multiple positive trials; it's now been taken down to only one positive trial in many cases. We see these therapies come out and they're the latest and greatest thing, and then subsequent therapy shows that they don't work. So I keep my eye on the new therapies, but when I look at my patients, a lot of times I see them not even getting the old therapies correctly. They're missing preventive measures that are tried and true and established. 

The fellows always want to talk about the latest trial of ENTRESTO or tafamidis for amyloidosis and I don't mind talking about that, but have you talked to your heart failure patient about sodium restriction? Do they understand how to weigh themselves every day? These are the basics that there's lots of literature on. It's not in doubt, it's not in question, and they get missed a lot. So this might be my own particular style, but I'm less attracted to the shiny new object that just came out in a clinical trial, and more like, are we doing the basics for these patients that we know work?

DR. DESAI: So, sort of tied to that then is, let's take your example of salt reduction. That's not particularly sexy or glamorous, but it's incredibly effective and hard to do. It probably doesn't take maybe four–seven years of training, in the way that we train physicians to do that, but it probably takes a health coach or someone that would actually follow up. I'm just curious, what are your thoughts on that? It's a big movement in some parts of medicine, but a lot of the chronic conditions that that you deal with every day are probably best managed by quitting smoking and losing weight and those kinds of interventions that may not require necessarily top board scores or top fellowship positions across the country, but just basically a listening ear. Someone that can really coach you through. Yet that's not necessarily what we're training for. Do you know what I mean? 

DR. RYAN: Yes, I know what you mean. It's a really interesting topic. Before my life got consumed by Boards and Beyond, my main focus was heart failure and preventing hospitalizations. We got into a lot of this, because usually, for patients with multiple hospitalizations, it's not because no one prescribed them the latest drug from a clinical trial. It's because of some basics like difficulty filling prescriptions and managing diet and things like that. My personal feeling is that highly-trained specialists, when they say things like that are important, it gives it a lot of credence it doesn't usually get. A lot of times in the trainee's eyes, and in everyone's eyes, that stuff is like pooh-poohed by the specialist, like, “Oh, I'm the surgeon, I don't talk about salt restriction, I don't talk about how to make sure you fill your prescriptions.” But when I was willing to give some time to that, all of a sudden it ramped up in its importance for everybody. 

So you can certainly farm some of that out. It may not be the best use of my time to go through every item in some patient's pantry and talk about the sodium quantity, but at the same time if I always say, “I'm the cardiologist, I only deal with, refractory A-fib, go talk to the nurse for your sodium management,” It becomes not an important thing in our field. So I think it would be wonderful if we had super highly trained specialists, who know the latest drugs and procedures and imaging techniques who also said, “Hey, I'll talk to my patient about how to weigh themselves every morning, and call me when their weight goes up to screen for swelling as well.”

DR. DESAI: That makes so much sense. I appreciate that reframing. So we have a lot of students and early-career health professionals in our audience that are going to be listening to you. What is your advice, your final parting words ab out meeting the challenges of the moment? You talked about the stress that they may be feeling, but you obviously have a longer career arc than a lot of folks that are just starting out. What advice or suggestions do you have for them?

DR. RYAN: The thing I spend the most time talking with the students I advise about is, you've got to find a way to stay positive in this career. To get into med school, I feel like you have to be so hyper-vigilant: When's the next test? What's my grade? Am I above the mean? What did everyone else get? Although that thinking gets you into med school, it also sets you up for a career where you're just going to burn out because there's always Step 1 and Step 2 and then who's picked for chief, and who got a fellowship, and who got promoted? It's a never-ending battle down a dark hole if you're always looking at what everyone else is doing and trying to measure yourself according to them. 

I spend a lot of time talking about—this term is so annoying to students sometimes, but for lack of a better word, wellness—and being happy and finding a way to draw satisfaction from simple things that you have control over, and figuring that out. It's a learned skill like anything else. It doesn't come naturally and you don't just learn it in one day, but finding a way to stay positive in this field is really the most important thing. You can start early on in medical school burning out, or saying, “You know what? I'm not going to worry about what this other person got in their UWorld percentage compared to mine. I learned something from the practice questions, so this was a great day for me and I'm gonna go to bed happy.” The more you can practice that kind of thinking, the better it will help you later on when there are long nights of call, and difficult times in practice, and all the things that you and I know about that you deal with every day as a physician. 

DR. DESAI: Well, that's a fantastic kind of piece of wisdom to leave us with. I appreciate that.

DR. RYAN: Sure. 

DR. DESAI: So thank you for joining us today. Dr. Ryan. Your career is phenomenal, and very interesting to hear your thoughts on how you would make changes. I enjoyed that.

DR. RYAN: Thanks for having me. Thank you.

DR. DESAI: Thank you everyone for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.