Technology and the Future of Medical Education - Part 1

Resonance is a student-run podcast aimed at showcasing the science at Baylor through the eyes of young professionals. Each episode is written and recorded by students who have a passion for research and the medical community. Guests on the show include both clinical and basic science research faculty who are experts in their fields.

Erik: And we're here.

Brandon: We are here.

Erik: This is the Baylor College of Medicine Resonance Podcast. I am one of your hosts, Erik Anderson.

Brandon: And I am another host, Brandon Garcia.

Karl: And I am Karl Lundin, I am the writer for this episode.

Erik: Yes so today we're gonna be talking with Dr. Agrawal and Dr. Pillow who are both physicians here at Baylor College of Medicine, and also have a specific interest in medical education, and how technology is influencing it, and how we can basically meld the two so that we can be more efficient with our educational practices, and kind of bring us into the new era of medical education. But before that I think we wanted to talk about a little bit of, you know, where have we come from with medical education and what some of the acronyms really that we're gonna be talking about like SAMR and VARK. So, Karl, you want to start us off?

Karl: Yeah, obviously, medical education is something that's existed for a long time. Going back to Hippocrates in the 5th century, people have been getting sick, and we've been trying to figure out how to heal them, right. And various schools and systems have been established. For a long time, it was kind of focused mostly on an apprenticeship model, so one or two students would follow around a doctor and kind of learn the craft from them through apprenticeship, just kind of studying them in that one-on-one relationship.

Erik: And that was for a while, right?

Brandon: Oh long centuries, right?

Karl: Yeah, we did not really start even getting away from that until towards the end of the Middle Ages when the university system developed. I believe the first medical school was in Italy, at least in the West, either the 9th century somewhere around there. And obviously, even there they were still doing an apprenticeship-based model. It was only over time there kind of developed this understanding as the university system grew up throughout the Renaissance— we're talking mostly about the development of Western today, not other traditions.

Erik: Yeah well and the apprenticeship model in America was around for until pretty I mean relatively recently like the end of the 19th century right?

Karl: Yeah so the idea of viewing the study in the education of Medicine in a very systematic scientific way didn't really get solidified at least in the United States until the very late 19th century, so the 1890s. That's where Johns Hopkins kind of got it's claim to fame, right. They were one of the first institutions to really start implementing a very scientific systematized way, and viewing medical education as a science, right, which requires laboratories, dedicated teaching facilities. The idea of the teaching hospital was something that was really kind of solidified and developed there. I'm going on rounds seeing patients, a lot of the stuff we think of today in modern American medical education would come sort of from that model.

Erik: Well, so how does, I guess, how do you think technology is kind of innovating this?

Karl: Well, I mean obviously, technological innovation has influenced medicine a lot even just from the transmission of knowledge. Originally people had to pass things on through oral traditions, right, direct one-on-one conversations, or you could have written works, but they would have to be handwritten. The printing press was a big revolution. Obviously, a lot of anatomical studies that took place, which we've talked about in previous episodes were really important for helping us kind of develop our understanding. And then also the university system, the development of various advances in the natural sciences were really important for advancing our knowledge, and then now we're kind of entering a new age of computers—the internet.

Erik: .com

Karl: You know the cloud, all these fancy electronics-

Erik: And we talked about the cloud with Dr. Pillow and Dr. Agrawal.

Karl: Yes, yes.

Brandon: I'm interested to hear a lot about with technology and things like that if there's any opportunity for simplification. Because I don't know how you guys felt but like with coming into medical school and stuff like that you've got firecracker, you've got Anki, you've got powerpoints; you've got Reddit, you've got all these different resources, full...chock-full of ways to study now. To me, like the biggest hurdle, I think for medical school wasn't necessarily the content so much just trying to pick out and figure out a way to-

Erik: What to use?

Brandon: Yeah, what to use, and I'm like, I'm a year deep, and I still don't know.

Karl: Well yeah and like streamlining that process I think is one of the big things that Drs. Agarwal and Pillow really focus on in their talks. They talk about for them one of the most important things they try to teach when they do their workshops and what not—and they'll get to explain this themselves—but is how do you curate all these tools. How do you pick and choose, you know which things are most useful, which are most salient for whatever task you're trying to accomplish, which is another really interesting thing we get into and talking about.

Erik: So can you tell us, because we will be talking about various educational I guess...you could call it philosophy or at least pedagogical styles, can you tell us a little bit about what some of those are?

Karl: Yeah, so, first of all, we're gonna talk about a couple of concepts in education today. The first is the S-A-M-R or SAMR model, this is kind of a model that's come into fashion recently, pretty recently, and it stands for: S which is substitution, A which is augmentation, M which is modification, and R which is redefinition. It's basically a framework that's used to discuss how we implement technology for education and the different ways that technological advances can cause sort of paradigm shifts in education through substitution, augmentation, modification, or redefinition. We'll get into that more when we have our conversation with the doctors. There's also the VARK model, V-A-R-K, which basically stands for visual, auditory, reading, writing, and kinesthetic. And that's the idea of learning styles, which is that different people have different preferred ways they like content delivered to them to help them learn. So a reader might prefer to read something and take notes, or as a visual person might prefer to look at like flowcharts and visual displays.

Brandon: And I remember taking that test, I think they had us all take that the beginning of the year, right?

Karl: Yes, yes, yes.

Brandon: And it helped for like two weeks, and I went right back to doing what I was doing before. I think it's kind of interesting, what they're gonna have to say about these models.

Karl: Well, the important thing about something like VARK, and I think we do get into this in this podcast, is that it's what works for you, right. And so it's all about customizing your education, and if you had already had what worked for you, then that's great. We also do get in a few other discussions about some things, like there's vocabulary like Bloom's taxonomy that's mentioned, which is basically just a taxonomy describing hierarchies of different levels of thoughts. So you guys have heard this, like synthesis versus just straight-up rote repetition and memorization, right. So that's just talking about levels of knowledge, not very important to know but for those of you who are curious, that's what that is.

Erik: Yeah well so, and it should...it's worth noting at this point that we're gonna actually be splitting this episode into two parts because we had such a long conversation with them and we think everything that we talked about is important for people to at least hear and mull over because it is very topical. And so we'll go in, and we'll have about a 30-minute discussion with them but please do tune in for the second part, which will be coming out shortly after. So to introduce our faculty that we'll be talking with, Dr. Anoop Agrawal received his BA from the University of Missouri in Kansas City, his MD from the University of Missouri in Kansas City, and completed his internship and residency here at Baylor College of Medicine, and is now currently the program director of the internal medicine and pediatrics residency program. Dr. Tyson Pillow, which is the other faculty member we'll be speaking to today, actually spent a lot of time here in Houston. He got his bachelor's degree originally at Rice University, and then he went and studied medicine right here at Baylor College of Medicine. He did his residency up in the University of Chicago in emergency medicine, and he came back here, and he is actually now our program director for our new emergency medicine department, as well as having roles as an associate professor and the director of a new simulation and standardized patient program. So we're very excited to get to talk to both of them, it's a fascinating conversation. We hope you guys enjoy it.

Karl: All right. Dr. Pillow, Dr. Agrawal, thanks for joining us. Just to start off, I thought we'd ask you to tell us a little bit about yourselves. So what's your background, what's your medical practice look like day to day.

Dr. Agrawal: Well, day to day here at Baylor College of Medicine, I am a program director for the residency program known as the combined Internal Medicine and Pediatrics residency program. And my medical practice, it's mainly in an academic and educational setting. So I am predominantly supervising resident learners, as well as student learners, and I do that both in the inpatient setting as well as the outpatient setting. You might encounter me over at Ben Taub on the inpatient wards, or in the outpatient setting also in the Harris Health System over at the MLK clinic.

Dr. Pillow: Tyson Pillow. Was actually a Baylor student here, went away to do residency. Came back. So currently also a program director for emergency medicine—actually helped start the program starting in 2010 here at Baylor. I'm also a vice-chair for education for our department, pretty busy, and very similar my practice is almost exclusively at Ben Taub. And so hanging out in the ER, seeing patients, teaching, etc. And then do a lot of work with other partners too, with resident education, but also faculty development, faculty education, etc.

Erik: So well, and as people listening to this will be well aware, today's topic is technology and medical education. We were just wondering what drew each of you to this?

Dr. Pillow: I think for me I've always been really enamored by the why of the things we do. So with medical education, there's so much to learn and do, and what you'll see is that early on maybe as a survival technique or otherwise, we find practitioners who we think practice excellent medical care and we do what they did, right. But there's still that layer missing that you want people to attain as their training, which is the why. Why are we choosing this treatment over that, why are we treating this patient a little bit differently than that patient based on their presentation? And that's what really kind of creates a lifelong learner and someone who understands what they're practicing rather than practicing the same way for the next 20 years as they did the last day of residency. And so when you look at tech, it really is a tool to get at the why, right. There was a time where we would use transparencies, and we moved to PowerPoint, and in some ways, the transparencies were a little bit superior because if someone asked a question that was off the planned didactic for the day, the lecturer could just write on the transparency to answer the question. So there's some freedom of movement. Most of our tools are great and as far as electronic tools, able to teach, reach a lot of people, but more recently we're seeing a lot of great tech that allows us to get outside of the standard linear teaching and go off-script, answer whatever questions may come up, think of things differently, and I think that gets to the why much more actively than we have been able to do in the past.

Erik: Well and by transparencies, so you're talking about overheads?

Dr. Pillow: Overheads right, yes, yes.

Erik: I remember that in elementary school and a little bit in high school.

Dr. Agrawal: Yeah you know for me, I'm not as poetic as Dr. Pillow in how I came to this, for me I was really, I'm a gamer, and I'm an Apple fanboy. So I just got to put that out there on front, I've never owned a PC in all my days, my first computer my father brought home was a Macintosh back in 1985 and never looked back. So for me, it was interesting that the two fields of technology and medical education were always separate, they never really converged and it wasn't until I think some time around when the iPad came to being that the two started to cross paths. And then all the potentials, just as Dr. pillow kind of alluded to, started to kind of go...epiphanies started happening. Aha, we can actually do this more efficiently, do it more engagingly, and make it more exciting. I will also admit, I'm also a former owner of a Palm Pilot. So if you guys remember those things so looking back and asking this question it makes me realize, I've always kind of dabbled in technology, as a toy, as a tool to try to make whatever I'm doing more exciting and fun. I remember us trying back in residency, 1998, trying to do our little H&Ps on our Palm Pilot, and people had created software back then and see how well that's done.

Erik: Wow, well I guess coming on that and you touched on this, but what would you say some of the core technologies that are innovating a change in medical education, especially that you guys are interested in, are?

Dr. Agrawal: I'll start off by saying what I'm seeing is, it's the whole movement to the cloud. I think that's really driving the ability to do asynchronous learning tenfold, and this may sound a bit controversial to say that, do you really need to go to med school for the first two years? And receive the training that we are currently providing. I think that's the gauntlet that we need to throw down, and what's the value that classroom education, or attending an institution education brings that you cannot get on YouTube, or Khan Academy, or someone else's podcast where they created some rich content, that's asynchronous and can drive and meet your needs. Rather than repeating reciting content that you already know well, and you're bored, and the content that's being discussed at the lecture is something you already mastered.

Dr. Pillow: I might piggyback on that specifically first and say that, so I agree with the gauntlet, the challenge that has to go out. I would even say that the answer to this challenge of when you look at LCME, ACGME, all the things we're changing, realizing the importance of wellness, of professionalism, of communication, breaking bad news, informed consent, empathy, etc. We are trying to cram all of this in the same four years of education, and so one of my potential answers to your...to the challenge is yes, we still need four years, but they need to look different, right. We should not come to class necessarily all the time to just get content. We shouldn't consider a PowerPoint that's delivered with facts to be, I have taught you this content. And I think the other thing too is really driving competency-based education as well, and so how are we going to challenge the status quo to not only say yes, you have seen and/or heard this content, but you can apply it. Because I guarantee your patience will appreciate when you can problem-solve actively with their issue and their complaint, rather than just recite something you've memorized from a course.

Erik: Pilocarpine.

Dr. Agrawal: One thing I see what Dr. Pillow is referring to is, I think the ability to do more direct observation. And I feel like we're right...we're almost there. Where I can taste that we're on the cusp of having the second area of core technologies, which is mobile tech and things like maybe Google glass 2.0. Things that you can actually take anywhere with you and do those exotic things of a direct observation where I can maybe directly observe you doing an H&P from my living room couch. And you're wearing the glasses in the hospital, and I'm watching you, and therefore limiting those constraints that we all come against as educators, which is time and ability to be available for them when the learning moments are happening or procedural work, you know in the ER, or wherever you have it. So I think cloud technology, mobile technology, and addressing the competencies, addressing I think direct observation is where I see, I can, again I feel like it's right there.

Dr. Pillow: Yeah, I agree. I think, so I'll add to...going back a little bit to your original question too, and building on what Anoop has talked about. I think the other thing to realize is that where Anoop and I do a lot of work with our other colleague—I'll send a shout out Jared Howell who's with the orthotics and prosthetics program—here what we see is that it's not that there are necessarily quote-unquote new technologies, it's that we have to go back and figure out how to innovate and do better with the technologies that exist, right. And so you get in a place where you realize that many courses, whether it be med school, K through 12—who is actually probably doing better than us from this standpoint—but high school education, college education, whatever it may be, we have these technologies, and we've stopped innovating, we've stopped kind of trying to figure out new ways to incorporate, right. So PowerPoint is outstanding as a tool, I'm a keynote guy but, and I have no vested interest in anybody, so that doesn't make me any money, but PowerPoint, keynote these are Prezi, whatever it may be these are outstanding tools, but you realize the uptake is just incredibly low. And that's where I think Anoop and I see when we go nationally, we've had the pleasure to talk nationally at many meetings, and you just see people, their eyes light up when they think, oh I can use it like that? I can do this instead? I can try that? And so these are actually existing technologies, which have been around for years as well as some of the newer technologies, the VR technologies, augmented reality, etc., right. I just...my son's just old enough to do Pokémon Go, right. So I am running around, making sure I'm not driving, and I realize we're behind the curve, but he loves it. So I'm running around catching Pokémon, and so you see Pokémon on top of your natural environment with the camera, I mean there...there've got to be applications to these things. So not even just the newer technologies and what we do with them, but actually, existing technologies and how do we leverage them better to again ask these why questions, and get to understanding an application rather than memorization.

Erik: Yeah, that's a good point.

Karl: So, what do you think is really interesting that's happening here at Baylor with education technology that you'd like to showcase? And then kind of as a follow-up to that we've been hearing about this SAMR model, I'm wondering if you could talk a bit about that?

Dr. Pillow: Yes, so we're doing a lot of great stuff at Baylor, there are many different people involved in the education technology push at Baylor, so forgive me if I leave names out. But for example, I know that Jim Walker, who's the nurse anesthetic program director, he has been using online courses for his trainees for a very long time. I mentioned Jared Howell, who actually has completely digitized his entire curriculum years ago and talks about that nationally. Anoop and I, along with Jared, we've been to several conferences, several institutions talking about different ideas of ways to do it—whether it be bedside or larger large group presentations, these sort of things. And I think that what you're seeing is a realization of how we leverage these tools. So, for example, we've had blackboard for a very, very long time at Baylor. Recently I've had the opportunity, great opportunity to work with our pharmacology course and the great instructors there, and we actually leveraged the discussion board, even just a simple tool as a discussion board of learning management system, and it got such great feedback that they've ...students actually have actually asked that discussion board be used more regularly across other courses to centralize questions, have a central area of answers, and expectations, etc. So again, I think a lot of it is not just innovating, which we're definitely doing at Baylor College of Medicine, but also just looking at the tools that are in front of us and leveraging them a bit more actively.

Dr. Agrawal: And you know you brought S-A-M-R, which is an acronym for a something known as we call SAMR. It's something that I actually first stumbled across back I want to say in 2013-14, and it's something that was actually developed by an educational professor in somewhere in the Northeast, I think maybe somewhere in Boston or Cambridge, by the name of dr. Ruben Puentedera. And what it was it's kind of answering what Dr. Pillow raised earlier. It created a framework for people to understand how to use these tools we're talking about. So before, as we said, people have these tools in front of them, like PowerPoint being a basic example, but they're not necessarily using it effectively in driving educational outcomes and learning. And so SAMR is an acronym that stands for: Substitution, augmentation, modification, and redefinition. And these are looking at how you can use technology to achieve the outcome you want based on the level and how it looks when you apply it. And surprisingly, as we alluded to already, those of us in undergraduate medical education, as well as Graduate Medical Education, are...we're surprised how far we are getting behind when it comes to the K through 12 and even college level, kind of evolutions that are happening in education. And SAMR, you find this concept very prominent in those other areas, and it's something that's still relatively new when you talk about those who are medical educators in terms of how they can use technology and integrate it into how they teach.

Karl: Okay, so yeah I think if I recall from my research on this we kind of talked about, it's in levels right? So, substitution might be considered like the most basic level of technology implementation, where basically using technology—like the example using PowerPoint instead of overheads—it's just doing something a previous technology did maybe a little bit more efficiently right?

Dr. Agrawal: Yeah.

Karl: Whereas if you go up to like modification, could you think of an example for something like that?

Dr. Agrawal: Yeah, a classic example, it's become now. I'm doing happy to see is becoming more ubiquitous is the flipped classroom.

Karl: Okay, okay.

Dr. Agrawal: Yeah, so same thing, right? You're using PowerPoint.

Karl: So flipped classroom, meaning it's a classroom where students would look at the PowerPoint and do readings beforehand.

Dr. Agrawal: Exactly.

Karl: And then they come in and do a problem-solving session or something?

Dr. Agrawal: Exactly, then when they are in the classroom, they're doing team-based learning. And you have cases that drive learning and students can kind of address their weak points rather than the lecturer just reciting the parent slides that are on the PowerPoint, which they could do at home. So example of taking asynchronous learning and also piggybacking on to a team-based learning, and that's again...you're using the same tool, we're still using the same technological tool to deliver the content, which is PowerPoint.

Karl: Yeah, yeah, but you're just kind of pushing the students to utilize it was in a different way. Could you think of like an example of redefinition or modification and something that you'd like to see implemented here in our classes?

Dr. Pillow: Well one way I've seen it done—and we've actually been successful in doing—is actually creating mind maps actively on shared spaces like by board, not to specifically advocate for one product or another, but that's one we use commonly. Whiteboard apps, Google sheets, Google Documents, where lots of groups...lots of different people even separated in in space, so we could be in different parts of the country, even the world, and work in the same space at the same time. And so that's redefinition because beforehand everything had to happen in the classroom at the same time with the same sort of proximity, now you can actually look at problems from different perspectives and bring even up to hundreds of people in the same space at one time to put their ideas together and create something new. So that's my example of redefinition.

Karl: Very cool, very cool. We've also, here Baylor, had a lot of talk about the VARK model for education. It's a model that has some debate going on in academic literature on education, so the literature in education. I was wondering what your guys' perspective on that was if you had any thoughts?

Dr. Agrawal: Yeah, so I'm, I think between the two of us I'm I think it's clear I'm more the VARKer, which I don't know if everyone that's listening to this understands...it's a concept of learning styles. Is there such a thing where you versus me have different learning styles where...it's an acronym again. V standing for visual, A auditory, R read/write, and K is kinesthetics. So it's implying that I can take this little questionnaire, it'll help me learn about myself. Am I a person who prefers to learn by visual, versus audio, versus read/write, and kinesthetic. And what you're alluding to, and which is very true, that there has been no study— double-blinded, placebo-controlled, etc. studies—showing that this...knowing your VARK style has resulted in better educational outcomes. And it kind of gets the heart of the question of what is learning...what does it mean to learn something and how do you demonstrate it. On the flip side where I come in as a kind of a pro still of VARKer is the idea of understanding that it also hasn't shown any harm. Because you have learned this about yourself, it...none of studies show that because you may try to approach something this way you have worse outcomes. So if anything it's neutral. And as we get into the further the conversation what I've seen is when I do try to create content that incorporates these different modalities, I tend to see greater engagement and...what we do know from literature is when you have greater engagement with the audience and the learner, there is a better outcome. And so tangentially I think it's worth trying to keep VARK in mind when you developed your tools.

Karl: So your kind of saying is like if I'm a visual learner, I might like to see visuals more. If you give me a book and say read the chapter and write a summary of it, maybe I could learn just as well doing that but am I going to engage with that as well and actually do it? As opposed to if you give me like, construct a flowchart or something more visual.

Dr. Agrawal: Right, and unfortunately the science or the at least the studies shown that given two people...give them the two different modalities and there's no difference in how they end up actually performing—in their abilities.

Karl: Right, so you think engagement might be better?

Dr. Agrawal: Yeah, and that's a really hard thing to put your thumb on, and I'm sure these things are hard things to actually study and measure and get definitive answers for. And that's where the creator of this, Neil Fleming, I think he's an Australian back in the ‘90s is when he developed this concept of VARK. That's how he defends it is...he says well, there's also no evidence against it in terms of again showing bad outcomes, and no one's really done a true double control placebo trial type thing. It's really hard to put your finger on.

Dr. Pillow: I think there's something in there, I'm definitely not a hardcore VARKer as It were, but I absolutely think there's something to the fact of, if we create things that are multimodal and engaged learners we will win, right. And what...I've had the privilege of taking a course on teaching online through Quality Matters recently that was a sponsored by the institution, so thank you very much, Baylor. But one of the things we get in that is, that you know when you look at a lot of these theories right, pedagogy versus andragogy, early learners versus later learners, dependent learners versus independent learners, etc. You realize that it's not just a one-size-fits-all for any one person; it varies by topic, right. If you were to put a medical topic in front of Dr. Agrawal and I we would be advanced learner's/teachers, right. If you put a recipe in front of me or I think Dr. Agrawal is an avid baker so that may not apply.

Dr. Agrawal: You'll have to ask my wife, I think she would differ.

Dr. Pillow: But in different areas, you end up being at different levels and need different things, and so I definitely agree there's preference—I have a preference with how I like to learn—but that depends on what I'm learning, when I'm learning it, where I met when I start, etc.

Dr. Agrawal: Yeah, it's kind of like Susie. If Susie says, you know I prefer to study in the morning, when it's quiet, at the library, that's a learning style. And does that work for me or you and so there's something...there's more to it. We can't...it's hard to-

Dr. Pillow: Exactly, and versus, no not versus but in conjunction with many of the theories that social learning is very social and you know medical is a perfect example of that there are parts there are times in med school where you got to go away, and you got to memorize the building blocks. And then there are other aspects of med school where you got to come in, and you gotta learn to work as a team, you gotta learn to manage a patient with other thoughts, consider things actively, so absolutely.

Erik: So just to summarize that it seems like the key thing that VARK is trying to get at is maximizing the individual's engagement with the material. Is that what VARK is kind of trying to get at? Is like how do you maximize your concentration on a subject?

Dr. Agrawal: I would agree with that. I'll present it in a whole different way. If we don't really care about VARK, then we really are wasting our time creating different multi modes of content. Why are we wasting our time? Just...here's a book. It's in...there's words in there. Just go at it, go at it read this book and you'll be fine.

Erik: Correct me if I'm wrong, but is that not how your medical education was?

Dr. Agrawal: Yes, that's correct, and look what I got, look where it got us.

Erik: Yeah, you guys are doing alright.

Dr. Pillow: We're doing alright, it's OK, we made it through.

Dr. Agrawal: But are there others who failed because maybe the content wasn't available? That's a hard question to answer.

Erik: Yeah, okay. We know as we've talked previously that you both, like you said before, have presented at national conferences conducting a three-hour mini-course at the Accreditation Council of Graduate Medical Education. Would you be able to tell us a little bit more about that?

Dr. Pillow: Yeah, that's actually pretty exciting. I think one of the things that has been great while we're doing this work, you know because we're both young in our careers. I guess technically speaking we can't call ourselves during your faculty anymore, we lost that that designation, but I wouldn't go senior faculty yet. We've come up with these ideas, we've had these experiences, and we go share them, and the response has been outstanding. You have the thing to realize at the end of the day is that everybody wants to do an excellent job and is looking for ways to do better. And sometimes excellent educators, like anything else, they may get stuck in their thinking or not know about new things coming out, etc. And so we've had the opportunity to go, we've actually presented at the ACGME meeting in 2018 and 2019 on this topic. I had a chance to do we did the AAMC a few years ago as well on similar topics, and I had a chance to do ACGME meeting back in 2013 I think. But even from this last year, so in 2018, it was great. We had a great conference. We actually got asked to do a webinar on educational technology, we did. And then got reaccepted in 2019 to kind of build on what we've done and we absolutely have plans to...the deadlines actually coming up, we're going to present it at the ACGME in 2020, fingers crossed, as well to continue this. And the uptake is, it's just outstanding. People want to do the best job possible for education, they like the innovation, and the...one of the things you'll see is that people have also had the realization—I think it's Eric Mercer who talked about this a lot—is that he was someone, I believe he's a college professor who was winning awards left and right, and then and realized that his students weren't actually learning the material. Right, they're passing the test, he was winning teaching awards, and so he went back and kind of redesigned his curriculum and actually makes the statement—there's some YouTube videos, there's some materials online—but makes the statement, he stopped winning awards but then the students started learning, right. So really going back to just the fundamentals of how we create content, deliver it, the expectations we put on students, application of that content, and we've just got nothing but excitement across the board as we do this.

Erik: So you focus...that's what your focus is? Is the presentation, or..?

Dr. Agrawal: No, it's a three-hour workshop, and that's I think what adds to the that's why people leave super excited, is we present them tools, and these tools are low-hanging fruit for how they can just literally walk out that door and start using them right away. And I think that's where...that's where when we get back to why technology and medical education is such a nice intersection, what's changing is all of the tools and things that these content products that you would create, normally you would have to, maybe ten years ago, you'd have to hire somebody. You'd have to hire a designer, a technologist to actually build for you. Now, these tools have become so simplistic and yet so powerful that anybody, you have to have very little you have to know how to turn on a computer on, and maybe you have to invest in a tablet, and that's it. And you've got everything in your control to create. And an example that we brought up earlier was, for example, on the iPads and tablets, there are apps that are whiteboard apps. So it's just like you have whiteboard, but you know the ability to draw and do so much more. Not just can you draw; you can actually I can have a former PowerPoint that I normally would just live in my desktop and never see the light of day except once a year when we give that lecture. Now, something comes up in the clinical arena, whether inpatient or outpatient, I have that PowerPoint with that slide that I want to share with you the Kaplan-Meier curve, or whatever, right there at my fingertips. I can pull it up on that whiteboard app, annotate, use it to teach and so when people see that in these workshops and get exposed to...you know they're like Dr. Pillow said, there they're excellent educators. They're looking for that new edge that can give them that new wrinkle of, yeah I was teaching that, but I was getting...it was getting old, it was just...it was it was tiresome. Now they leave with a little more fire, a little more excited to go out and say, you know that's really cool, I can add that new wrinkle to my tool deck.

Erik: As you say that it makes me think like when we touched on this before but...how you guys kind of came upon this. Did you come upon this yourself like to learn how to use a whiteboard? Like how did you guys decide, like hey, this is actually a great tool? And so you know Dr. Agrawal: Yeah for me it's a very clear, I have clear dots that connect, that I connected and it was...there was a professor at Baylor College of Medicine back in the late 90s. He would win all the teaching awards. And one of things that he did that was so unique. He walked around with a whiteboard that was about-

Dr. Pillow: Dan Hunt.

Dr. Agrawal: Dan Hunt, yeah professor Dan Hunt back in the early 90s, the late 90s, would walk around on medicine wards with a whiteboard that was about four by 6 feet. Not small. Not one you can put in your pocket and you can hide and like, I don't have a whiteboard. No it's right there, you cannot avoid it, and you always saw his team in the hallway gathered around that thing propped up on the ledge, and he had figured out back in the 90s what stimulated individuals, got them to learn. And again, for him naturally, those teaching awards followed. And so I was too shy and insecure myself to mimic that, and I haven't seen anyone else do the same in terms of that size whiteboard. I've seen folks walk around with a kind of a normal 8 and 1/2 by 11 type. But then around when the iPad came out in 2009 or 10, whenever, it was...that's when something clicked. I don't know what that...how that epiphany happened, but I say hey, I got curious that on this device, could there be something similar that is a whiteboard app. And I will tell you it was not really there in 2010/11. It took a few years of hunting. I used some things that were kind of close but not quite, and in really around 2013 developers started you know creating some really exciting applications.

Dr. Pillow: Yeah, I think for me I've had the, I was a paramedic in college, and I actually didn't stop my education. So there were two semesters where I took over 20 hours of coursework across two colleges, as well as ambulance rides and everything else so, that was fun. It was actually fun. I really enjoyed it, so something's wrong with me, I know. But the, so I learned the basic rote memorization necessary to you know be a paramedic for me at the time. I'm not saying that's all paramedicine training, but at the level, I was doing it that's where I was. And so when I got to med school, I realized I kind of know enough of the basics to know I don't want to just know facts and started to kind of dive deeper. And then, as I started to do this more and more I also realized that I had a real love for presentation design, and a lot of my early work as far as presentations and conferences was on doing presentation design better in a way that facilitated education. And there are actually two nice articles by Dr. Issa et al. I-S-S-A, that actually look at modified slide design and how it enhances education, looked at in the surgery clerkship context. And so as I was doing that, I realized that the core of presentation design is not only great design, but also limiting the message, kind of streamlining what you're saying, and then also creating flexibility in the presentation. And so then that naturally led me to say, how is there some way to have active flexibility in the presentations rather than planning it, right. You can plan for an arrow to come into a PowerPoint presentation at any point in time. It's really hard to plan when the students gonna ask, or another learner is going to ask a question that's three slides down or two slides back. And so that's when I started to find those same sorts of tools that allows you to really just minimize the slides you use and maximize the active learning aspects of things and the engagement. So that's where that piece came from as well, and the last part is that really love curriculum design, and I will give a shout out to our faculty development group here as well that do an excellent job of kind of making sure that core piece is there too. And so I realized how important that was because at the end of the day the tech is just the tool. I think where people make the mistake is they grab a piece of tech, and they say I want to use my iPhone. They don't know what they're gonna teach; they don't know what's going to...they just decide they're gonna use your iPhone. That's not how it works, what you figure out is how are you going to deliver this content, what ways you want to get it across, and then ways tech can actually get there better, more efficiently, more actively. And I love that idea. So I think as that built on itself, I just became enamored with this idea of using tech to just do what we're doing better.

Erik: Well and I'm curious do you guys try to give...like tell that story at all? About how you came upon this? Because I mean we all know teach a man to fish...he'll, you know. It's like if you instill those skills of like actually trying to think about how to innovate as you go. I'm just curious.

Dr. Agrawal: That is a core, core piece. That's what we start with. Because these are educators that we're talking to. So they need to hear that buy-in of just that. We're not just, and it gives us more validity in what we're trying to share. We're not, because one thing we do emphasize is we're in 2019, and these are the current tools we have. So we can walk out of that workshop and the next thing you know Google drops a new device and everything we've just discussed, and the tools we've shared are now antiquated and no longer applicable to what we want to do. So we're trying to teach concepts and frameworks, hence why SAMR, VARK, these are frameworks of how to package the technology into things like Kern's model of Education and in Bloom's taxonomy, which are core pedagogy principles. So that people when they encounter on their own they'll discover a new technological tool, they can take that tool and put it into action in a way that's effective and creates and promotes active learning.

Dr. Pillow: Yeah, we actually have slides to that effect in the presentation, talking about it's just a tool; it's going to change. We make references to Google glass and those sort of things as success...some success stories, some failures around that area. But again, really just echoing what Anoop said, really making sure they leave with the idea of, and that's where also the cloud technology is so critical to...because if there's any piece of tech that isn't going anywhere in a while you know and can be used as an anchor for most, almost every major tool one can use has a functionality to connect to the cloud, right. So how do you create content that lives in an accessible protected, HIPAA protected, encrypted safe but accessible way, and then utilize that across platforms where that platform is currently available or doesn't even exist yet.

Karl: Hmm, fascinating.

Erik: Very interesting.

Brandon: All right, that is it for now. We would like to thank everyone out there who took the time to listen to this episode of the podcast. Special thanks to Karl Lundin for writing the episode. Thank you to our faculty advisor Dr. Poythress for helping us put everything together. Thank you to the Baylor communications department for helping us with the production and website. And thank you again to Drs. Pillow and Agrawal for taking the time to be interviewed with us. We hope everyone enjoyed it and hope you tune again soon. Goodbye for now.