Tools to Personalize Medical Education - Dr. Phil Xiu, Editor-in-Chief for Elsevier’s ClinicalKey Student Assessment

Michael Carrese: Hi everybody, I'm Michael Carrese and today I'm delighted to welcome a member of the Elsevier family to raise the line. Dr. Phil Xiu is the UK Editor-in-Chief for ClinicalKey Student Assessment. That's a question bank which integrates Elsevier's ClinicalKey platform and resources with high yield questions designed for students. He has a deep background as an educationalist and strong interest in research. He's the series editor of the globally renowned Crash Course series of fourteen medical textbooks which has sold over a million copies and has been translated into eight different languages. Additionally, he serves as an elected council member of the Association of Medical Educators. And as if that were not enough, Dr. Xiu is also Chief Medical Officer for Medicalchain.com and practices

as a family physician in Leeds. 

It's a pleasure to have you on the program today. 

Dr. Phil Xiu: Thank you very much, Michael. It's a pleasure to be here. 

Michael Carrese: So, we always start with getting some career highlights, and more particularly we like to know from the clinical people why they were attracted to medicine in the first place.

Dr. Phil Xiu: Absolutely. Love to give you a bit of my background. When I was growing up as a first-generation immigrant in Great Britain, I was amazed by the support that the local communities provided to me and my family, and really this made me determined to make a positive contribution back to my own community and those around me. That's what first drew me into science and eventually to medicine because I can make that contribution. I was particularly fascinated by the idea of using science to improve health outcomes and help people in need. 

When I was sixteen -- so much, much younger than in the US system -- I had to make a real difficult decision between pursuing the humanities or science, but I ultimately chose science and I'm really glad that I did. But even though I was really passionate about science and medicine, I really never lost my love for literature, for writing, and that's what eventually led me to my current role as a medical educator. I've got a unique opportunity to help shape the next generation of healthcare providers and to share my passion for both medicine and education. It's truly a dream come true for me. 

Michael Carrese: Tell us about your path to Elsevier and fill us in a little bit more on your current role there. 

Dr. Phil Xiu: Sure. Going back in the day when I was just a medical student, I really stumbled upon a little gem of an opportunity, and this nucleus has really crystallized my career from that point onwards, really. It was, in essence, an advert in an email newsletter for an author position to update a medical textbook under the Crash Course brand. Let me tell you now, Michael, when I was young and naive as a medical student, I was so excited to have that opportunity to have my own name in bright lights on the front cover of a medical textbook. It was something to really aspire to. But then I had all these doubts, these negative thoughts that started creeping. What if I don't get the job? What if I'm not good enough? What happens if the reviewers don't like the book? I spent days weighing the pros and the cons. 

Eventually, I mustered up the courage to apply and I was really, really nervous for that first interview. Back in those days -- before Zoom and online holograms, et cetera -- it was conducted over the phone with a founder and the original series editor, Dr. Horton-Szar, and then there was then Jeremy Bowes who was the content strategist at Elsevier at the time. I remember that day. I was pacing back and forth, back and forth all the time in my apartment, sweating bullets and I was really hoping, beyond hope, that I'd make a good first impression over the phone.

To be fair, it was the first interview I'd had for a proper job at that age, and I was naive. I really thought the best way to come across over the medium of the telephone as a learned and academic individual was to put on my suit and also wear my academic gown over the top. 

Michael Carrese: (laughs)

Dr. Phil Xiu: I studied at Cambridge Medical School, and we have these gowns and that we wear for formal events, very much like Hogwarts. So now, I was wearing the suit with my gown over the top, sitting down on my chair, ready to take the phone call. Unfortunately for a young and naïve Phil, I had really underestimated the laundry capacity of the dry cleaners then and I didn't have any suit pants. 

Michael Carrese: (laughs)

Dr. Phil Xiu: I'll be honest, Michael, I was in far too deep. I was committed, so I needed to see that through. You can imagine me...I was in my own student bedroom on my chair, no pants, with an academic gown on, because that's exactly what a rational student would do during a telephone interview. 

Michael Carrese: (laughs)Of course. 

Dr. Phil Xiu: Pretty much a sight to behold. Now, Michael, I want to reassure you right now, I'm fully dressed, okay? I've got pants on for this interview. 

Michael Carrese: Well, we have some standards on this podcast and that's one of them. So, you guessed correctly. 

Dr. Phil Xiu: We've got to raise the line somehow. 

Michael Carrese: (laughs)So you’ve got to tell us, did you get the job? 

Dr. Phil Xiu: Well, during the interview, do you know what? I must've made some good impression or maybe the pant-less method worked because I was offered the job, being the author of that edition of the Crash Course medical textbook on pathology, as it happened. And to be fair, looking back on it now, it felt really like yesterday that I took that leap of faith and applied for that position for that medical textbook. I couldn't have imagined the journey that would unfold from that single opportunity that stemmed from that day. 

Fast forward to now, I've had the real privilege of being part of various exciting projects in medical education and health tech with Elsevier, from writing textbooks to becoming the series editor of the Crash Course book series, to being the editor-in-chief of Elsevier's Clinical Solutions, the order set platform, as well. Really, it's truly been a journey filled with a lot of growth, a lot of learning, a lot of opportunities to make a difference in the lives of a lot of people -- both professionals and patients alike -- and all of this has cumulated in an opportunity to be the editor-in-chief of Elsevier's ClinicalKey assessment platform, and that's been a highlight of my career along with more recently being elected as the council member for the association of medical educators. 

Michael Carrese: Well, congratulations on all of that. You have compiled quite a track record there. And I'm wondering, particularly for the medical students and early career folks in our audience, that's a tremendous load to balance and to also be still practicing. So, do you have any tips on how to juggle all of that? 

Dr. Phil Xiu: It's tricky, isn't it, Michael? It's tricky. In our lives, there are so many different things that pull us in different directions. But I find that the best barometer as you go through this life's journey is to be true to yourself, is to have passion projects that you really, really believe in. Because if you have these projects that you really believe in, work doesn't really seem like work and, in essence, you feel as if you're living the best possible life that you can live. That's what matters, because if you can balance all of the different projects that excite you, that make you wake up in the morning, that is what you want to achieve, if you can. It's something to aspire to, and obviously, everyone had to grind through all of the hard work to get to where you need to be to reach that space. 

Michael Carrese: Wise words. So, let's get into some details on ClinicalKey Student Assessment. But first, for folks in our audience who aren't familiar with the whole ClinicalKey offering, can you tell us about that?

Dr. Phil Xiu: Happy to, Michael. Elsevier's ClinicalKey Student provides medical students with an online learning environment and the aim of the platform is to help students build the knowledge, the confidence, the skills that they need throughout their own careers. The platform is linked directly to the medical school's individual learning management system, so that really means that faculty or instructors can support students by assigning content that supplements the student's own curriculum and enhance the faculty's own lecture materials with images, illustrations, and any other resource directly from Elsevier's library. So, you know, there's no need for me to Google for pictures of a skin rash just to put in a lecture slide because you can take it directly from Elsevier's journals and image bank, all copyright cleared and ready for use in medical education. 

Now, the platform itself includes access to hundreds of textbooks that students have loved throughout decades, including Gray's Anatomy for Students, Medical Physiology, as well as any videos on topics like anatomical dissections and clinical examinations. Faculty and instructors can also use the platform to create their own assessments and informative assignments which are linked to a dashboard that provides that performance metric and suggests reading based on the student's own performance. So overall, ClinicalKey Student provides a really convenient, I feel, and really quite user-friendly way for medical students to access the resources that they need to succeed in their own studies, and also for the faculty and instructors to help support and track the student's own progress as well. 

Michael Carrese: It’s a very powerful platform, and so ClinicalKey Student Assessment...tell us about that. 

Dr. Phil Xiu: So the ClinicalKey Student Assessment platform itself is within the ClinicalKey platform. Really, the aim is for faculty to be able to assign these assessments and these assignments for students based on what they're learning. As an example, if a student was doing cardiology or doing cardiology placement or an observership somewhere, then their own faculty instructors can assign the students to do certain number of questions or assignments or a certain number of readings within the ClinicalKey assessment platform, and then students are able to do it. But more importantly, faculty can see and can measure and can track their progress, and then can also advise and assign a more individualized set of questions based on what they're learning at the time, or based on their previous performance. 

So, I see it as really having a global reach but having a really local input and also output for the student's perspective, whereas they can get some one-to-one formative assignments and one-to-one formative feedback, whereas they might not be able to using other types of platforms. 

Michael Carrese: Well, it's almost real-time feedback. 

Dr. Phil Xiu: Almost, almost, depending on, obviously, the time it takes for the faculty or instructors to feedback and also give further assignments. But obviously for the student themselves, they will get immediate real-time feedback from the platform based on their answers and based on their own readings, and they're free to explore the platform themselves. The guidance from the faculty is really the cherry on the top. 

Michael Carrese: Yeah, that sort of tailored, personalized feedback and direction...that's very powerful from an educational standpoint. I mean, I'm not a pro or anything, but it seems like if I'm the student, that is a terrific way to achieve progress perhaps more quickly if you've got somebody who's zeroed in and said, “Oh, okay, so I saw you missed those three questions on X, so I'm going feed you some information on that.”

Dr. Phil Xiu: Absolutely, Michael. And this personalized individual learning journey that students will go on...that's the same throughout their career, because even if you were a doctor, you will know there are areas of your own knowledge that you are missing, as an example, and you will know how to remedy it through good self-reflection and you will focus on those areas where you're missing that knowledge chunk. Now with Elsevier, we give that first foundation, that first step to help students by linking up the faculty and instructors into a platform where it's much easier to use to help them in that journey of self-discovery and self-learning, which hopefully will set them up for the rest of their careers.

Michael Carrese: Now, I understand that one of the projects you're working on is reviewing content with an eye on diversity, equality, and inclusion. Fill us in on that. 

Dr. Phil Xiu: Yeah, at Elsevier, we understand the critical role that diversity, equity, inclusion play in medical education and healthcare. That's why I've been working with our team to assess the educational content -- including the images, the illustrations, the text -- to make sure it really accurately reflects the diverse backgrounds of the patients our users they’ll be treating in the future. We're really committed to promoting a real inclusive and equitable learning environment and providing resources and support on topics that relate to diversity, equity, inclusion, such as unconscious bias, cultural competency, and anti-racism.

One of the specific areas we're focusing on is the review of our assessment questions, particularly in the context of these clinical vignettes that precede a question. It's essential that these questions must be inclusive and really must be representative of the diverse patient populations that they will encounter in a future career. So, for an example, having images of skin pathologies in a variety of skin colors and backgrounds, rather than just the traditional textbook photo of a rash on white Caucasian skin. 

Sometimes exam questions are really famous for having what I call caricatures of peoples and occupations. Let me give you some examples, Michael. There may be clinical vignettes and questions involving lorry drivers when they present clinically, and invariably the answer will always be diabetes. The owner of a pub in Great Britain will always have an alcohol-related disorder, or a businessman flying on a business trip to an exotic land alone will always have some type of sexually transmitted disease as a diagnosis. Those are some of the real extreme examples of these vignette descriptions. 

Now, that's really bad from a student perspective, and learning these sorts of biased associations, rather than the clinical outcomes, is also quite disrespectful. So, we're looking at the language used within the questions. We want to make sure it's respectful, and also really is educationally useful for the students. We really want to give students a good understanding of the needs of the different patients and the ability to provide culturally appropriate care, and to do that, we must make sure that our content is free from bias. 

Our goal, and I'm sure you'd agree with me in this, Michael, is to prepare students for the realities of medical practice and provide the best possible care to all the patients, regardless of the background that they have. I believe that by promoting diversity, equity, and inclusion in medical education we can really create a more just and equitable healthcare system for everyone concerned. 

Michael Carrese: So, process-wise, how do you know that you've got it right in the end? I mean, are there people being brought into the process that haven't been involved before, you know, to get a fresh set of eyes on it, or how are you going about it? 

Dr. Phil Xiu: Absolutely. We have an internal editorial process which is tweaked and changed all the time based on student feedback, based on faculty feedback from the hundreds of faculties in terms of institutions that use ClinicalKey Student Assessment platform. By that, we mean each individual institution has their own EDI criteria and their own guidelines that they want to follow themselves, and we take the best practices of all of them and ingest it into our own editorial process so that we make sure that all existing content which is a work in progress, as well as any new content that comes into the platform, is sure to be screened for these types of things we need to be aware of. 

Michael Carrese: You know, the other thing I'm curious about -- and we did mention the different hats you wear -- is how practicing still as a physician informs or affects your work as an editor and vice versa?

Dr. Phil Xiu: I think it's vital. I think it's really, really important to have a grounded view on life and on the patients that we serve. As an example, because I practice in family medicine, I serve my own local community...not for a long period of time per week, per se, but I think it helps keep me grounded and it helps me to be at the frontline of medicine because these are the patients that I will see day to day, and these are the future medical educators as such that I want to train to be able to see these patients of tomorrow. I want to be able to look at a patient in the eye and to be able to tell them and give them the best possible medical advice as well as treatment that we would teach the students themselves using the platform. 

That's what we really aspire to. I want to be able to use the platform as something of a springboard for students to do their own journey for their own career, for their own self-development. Certainly for myself as a medical educator, I think having that foot in the door where I'm seeing patients directly -- I'm asking them questions, I'm understanding them, I'm seeing them not as a disease on a platform or in a textbook but I'm seeing them in real life through all their complexities -- I think makes it so much more rewarding at the end of the day for me. 

Michael Carrese: No, that all makes sense. So, let's touch on Medicalchain for a minute. Can you give us an overview of the company and your role there? 

Dr. Phil Xiu:  Sure. I'd be happy to give you an overview of Medicalchain. Medicalchain is a cutting-edge healthcare technology company that's really leading the development of methods to integrate blockchain technology into the modern healthcare system and our goal really is to empower patients by giving them complete ownership and control of their health data. Now, in recent decades, technology has played a very significant role in the medical consultation model. Physicians are relying very heavily on computers as their digital assistants and this integration of technology in the medical field has for sure allowed for more efficient treatments of patients and a decrease in misdiagnosed or misunderstood conditions. And I know, Michael, obviously Osmosis is very passionate about these rare zebra conditions that we were discussing before. 

Michael Carrese: Absolutely. 

Dr. Phil Xiu: Now, a part of the sort of large, centralized patient databases that have emerged, especially in Great Britain, as a result of the modern national health systems is they often store data in separate data silos and they're really governed by different gatekeepers. That makes it really difficult for a physician to access all of a patient's health records and indeed, it's really difficult for patients to have access to their own health records. 

As an example, if a patient was on holiday in London, whereas they normally live in Leeds, and they see a doctor in London for whichever health condition that they have, well, as a family medicine practitioner myself, I won't be able to have that access to the data nor the results that they have in London and certainly the patient won't be able to have it directly either. That's where the blockchain technology comes in.

Medicalchain is at the forefront of using blockchain technology to really improve the quality of medical consultation and empower the patients by giving them access to their own health records. I think that by involving patients in their own healthcare decisions, I really believe that we can improve the accuracy of diagnosis and treatment plans. Our aim is to bring that shift in healthcare by providing that patient-centric approach. I'm very proud to be part of this development and I really believe that as medical systems throughout the world continue to face new challenges, the patient-centric approach by integrating different data silos within healthcare will become more and more necessary for sure. 

Michael Carrese: Is part of the reason blockchain is involved encryption for patient privacy, or why does using blockchain help with this unification of information? 

Dr. Phil Xiu: Yeah, you hit the nail on the head there, Michael. A blockchain is basically a small database that's distributed across a network of computers that keeps an identical version of the truth. So, this technology enables individuals to have complete ownership and control over their own data cryptographically and eliminates the need to trust any one institution with their own information. It really distributes that in a way. So, exactly as you said.

Michael Carrese: Excellent. So we, as you know, are part of Elsevier, an education company, and we love to fill knowledge gaps. One of our favorite questions for guests is to identify something that they really care about where they think, you know, most people just don't know it, or they believe a myth about it or there's just a gap of some kind. What would that be for you? 

Dr. Phil Xiu: Do you know what? I think the one topic that would be incredibly impactful for Osmosis to cover -- it really is a major topic -- is how to widen access for medical student applicants from diverse backgrounds. In Great Britain -- and I'm not sure what the stats are for the US -- but in Great Britain, 80% of medical students come from just 20% of high schools. That is an incredibly stark statistic of the lack of access to medical education from these students who are from maybe disadvantaged backgrounds. So, I feel there's a real need for increased diversity and social mobility within the medical student recruitment process, and, to be fair, healthcare as a whole. 

I think it'd be great for us Osmosis to create content on the mechanisms that can help assist with widening access, bursaries, scholarships, mentorship programs, and how high school students may get access to them. Because I think it's really important to empower these aspiring health professionals from these diverse backgrounds who would otherwise not pursue a career in medicine. I know that Osmosis has videos on MCAT and how they apply for US medical schools, but having maybe a deeper video series that offers further advice on how to navigate the intricacies of the medical school application process can help widen the access and really create a more diverse and representative workforce. I think by doing so, we can bridge the gap in these disparities of healthcare outcomes and we can inspire a new generation of potential health professionals to follow their own dreams. 

Michael Carrese: That's an excellent idea. In the US, there's been a lot of attention paid to the very low percentage of African Americans that are physicians, and other guests have talked to us about the importance of efforts of introducing the very idea that you can be a physician to communities of color at elementary school age, middle school age to start demystifying the process because they may not know anybody that's applied to medical school before and don't realize all the steps. And, of course, there are a lot of costs involved as well. So, some of these groups are focusing on that piece of it. But in the end, a lot of it is just getting them to understand that they belong in that arena and that it's possible for them.

Dr. Phil Xiu: Absolutely, Michael. And you know what? Inspiring these new generations of potential healthcare professionals who thought they might never be at that stage -- just by simply inspiring them and showing them that it can be done and by simplifying the process -- I think you would have a much better chance at diversifying any potential medical student makeup within any organization. I mean, the statistics I gave you before -- 80% of medical students in the UK and in Great Britain come from just 20% of high schools -- what's happening to the rest? It's incredible, isn't it? Certainly, it's not reflective of the patients that we see on a day-to-day basis in terms of makeup and in terms of diversity. So, I think having that diverse makeup will make the workforce more resilient, more robust and it probably will give better health outcomes, too. 

Michael Carrese: Well, that's a terrific thing to focus our attention on. So, as we wrap up here, I know you have particular interest in supporting the career development of healthcare professionals. We've already heard some great advice about finding a passion. I believe wearing pants during interviews was another piece of advice. 

Dr. Phil Xiu: (laughs)

Michael Carrese: What else do you want to leave our audience with along those lines? 

Dr. Phil Xiu: Sure, I'm happy to share, Michael. I mean, first and foremost, I think it's important to keep in mind that in healthcare, it's all about serving others. When students might be thinking about clinical or leadership roles, I think you got to make sure it's patient-centric and it's focused. That means you need to put the needs of the patient first and foremost, and make sure that everything you do -- whether in business or in life -- is aimed at serving them in the best possible way, whether that's at the individual level or at the population level. I think that if that focus is the forefront of both your work and career trajectory, you'll make a big impact on the health system and the lives of the patient that you serve. 

As we discussed before with that anecdote on the pants, don't let fear hold you back, nor the lack of any pants, to be honest. When an opportunity comes your way, embrace it. Take a chance. Step out of the comfort zone. Face your fears head on. I think that's where you'll find growth and that's where you'll find fulfillment. Take a deep breath, trust in your own skills, trust in your own abilities, and just go for it. 

If you chase an opportunity -- even when it come with all of your fears, your uncertainty, your doubts -- I think it will lead to new experiences and new knowledge whether you're successful or not. So I'd say, don't be afraid. Chase your own dreams, follow your passion, because you never know where all of that will take you. As I said, Michael, when you asked me before, you've got to stay true to yourself and do what feels right for yourself and your own family. I think that's critical. 

Michael Carrese: Well, that's a wonderful “wisdom drop” as the kids say these days, and we really appreciate you spending time with us today and sharing all that with us. 

Dr. Phil Xiu: Perfect. It's been an absolute pleasure to be here, Michael. Thank you for having me on the show. 

Michael Carrese: I'm Michael Carrese, thanks for checking out today's show, and remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.