Not Dumber, but Different? Counterpoint from a Millennial

Not Dumber, but Different? Counterpoint from a Millennial

This evening I read the article Dumber Doctors on the blog Glass Hospital and just had to respond. John Schumann concludes his article stating:

One concern that has a ring of truth to it is that young doctors have become great “looker-uppers,” and have lost the sense of what it’s like to actually read and study medicine. While doctors enter the profession with a commitment to lifelong learning, some of us fear that the young folk only go far enough to commit to lifelong googling.

While I replied initially in a comment on the forum (and am not the only one to disagree with this stance), I have taken the opportunity to respond more formally because I have found that too often we have this conversation muttering under our breath instead of out in the open.  Boomers/GenXers mutter about us “not paying attention” or “not studying enough”.  Meanwhile, while we Millennials mutter about how our exams are “just about memorizing a bunch of bull$#!* that will be out of date in 5 years.”

Protesting too much?

I am a Millenial who will be starting as an attending this year. I still passed my exams and still had to deal with learning the “old fashioned way.”  In the end, memorizing factoids and endless lists was the way to beat the exam, but these skills do not always translate well into my daily practice as a physician.  I am certain studying to add to my existing knowledge about cytochrome P450 or the oxidative phosphorylation chain will help someday, but rarely does that problem present itself in my emergency medicine practice.

I think that a big problem underlying the current examinations systems in most specialties and jurisdictions is that they ask questions that often have not changed with the times.  Most importantly, they value the lower levels of learning (e.g. Bloom’s Taxonomy level = ‘Remember’ and perhaps ‘Apply’) rather than critical reasoning and problem solving.

Ego vs Superego

My experience with “googling” is that it has prevented medical errors and possibly saved lives.  I can recall several occasions when I have being presented with a difficult patient problem and turned to the wisdom of the internet to resolve the issue.  I do not, however, just go to the first random website I find, but use legitimate resources (usually peer reviewed articles, guidelines, etc..) to support and guide my decisions.  In the past my ego (or dare I say, my Id) might have had me presenting arguments to my colleagues that are unsupported by the literature.  Instead, my colleagues and I use our superegos and, with the assistance of the internet, arrive at the best answer for the patient.

The days of holding all of medical knowledge in our heads have gone the way of the dinosaur.  The lawyers have long known that it is not your actual memorization of the law that makes one a great lawyer, but what you do with it.  Most other professions do not kid themselves into thinking that their experts can remember it all.  Instead, they allow for open book exams (e.g. the Bar exam, the Canadian Accounting exams) – because it is the reasoning and articulation of thoughts that demonstrate true knowledge.  The vast sum of medical knowledge is now much larger in volume than any criminal code or even the tax code, so why are we so stuck on the idea that our doctors should just ‘know it all’ (and off the top of their heads)?

Teaching and Striving for a Higher Level (of Learning & Best Practices)

When we ‘pimp’ our medical students we ask them about core knowledge, something that can be easily accessed by Google now.  However, it is not whether they have memorized a fact or can look it up quickly that will make them a great physician.  In fact, by making memorizing factoids and statistics the mainstay of medical ‘expertise’, we have historically relegated other important aspects of our job (e.g. interpersonal skills, leadership, etc.) to the wayside.  Certification exams like the ABEM/ABIM can not measure whether a finishing physician can convince a patient to be adherent to a regime of medications or lifestyle changes.  It can only measure that he or she knows that the patient could benefit from that intervention.

So, I pose three questions:

1) What use is that knowledge if effective action does not follow?
2) And, why do our exams not focus on the difficult clinical reasoning required to treat challenging patient presentations?
3) Finally, why do our exams not ask us to negotiate with standardized patients or nurses in difficult situations?

Likely because these skills are difficult to examine. And so, as educators, we have chosen the path of least resistance and given our learners a scantron sheet and #2 pencil.

Luckily, there is change afoot as leaders in medical education have laid the groundwork, and are now bringing us forward towards a new era of competency-based medical education.  In response to Dr. Schumann‘s blog post, Dr. Jason Frank stated on his twitterfeed that:

Not “Dumber Doctors,” just the Harbringers of Change

I would like to stand up for my generation in saying that we are not dumber doctors as was posited in the Glass House piece.  We are just different.  We have been taught with frameworks like CanMEDs and the ACGME Competencies and we see the practice of medicine as more than just bubbles to be filled in, or lists to be recited.

In his final point, Dr. John Schumann notes that:

in today’s era of restricted work hours, something has to give. Too often, when residents must complete the same amount of work in a limited amount of time, what’s sacrificed is the didactic portion of the education: the stuff we do by running through case after case, discussing subtleties and action plans. When time is limited, the work’s simply gotta get done.

Since work hours restrictions limit clinical work, using this logic shouldn’t exam scores have gone up? Much of that self-directed memory work we call ‘studying’ is not best done at work.  Have you ever tried to read a chapter of Rosen’s Emergency Medicine while seeing 30-something patients in a busy Emergency Department?  Is it even possible to memorize approaches to malaria and other parasitic diseases from Harrison’s while on call for Internal Medicine and admitting your 4th patient with a COPD exacerbation at 4am?  If you think about it, if “reduced work hours” has anything to do with pass rates on exams then it should have translated into more off-the-clock studying time and increased pass rates.

To think that residents learn only at work is highly teacher-centered.

A Call for Change

We Millenials are a group with little agency in the matter of how we write exams. However, I posit that our whole examinations system need radical change. While studying for my final examination in residency, I was advised to answer questions as a ‘expert doctor from 2008′ instead of an expert and up-to-date doctor of 2013 because my examiners and the exam-setters will not have read the 2013 update on STEMI care, nor the 2012 IDSA guidelines, etc.  Many colleagues and friends have recounted similar quandaries when sitting for their exams.

Not only do these examinations test lower levels of knowledge because those are the easiest to test, but they may have far more insidious implications for professionalism and patient safety.

Cure the ‘My-Brain-is-Bigger-than-Yours’ Syndrome

The current system from medical school onward highly values guessing and intellectual bravado (or as I like to call it, the ‘My-Brain-is-Bigger-than-Yours’ syndrome).  In a field that should value double-checking and the use of guidelines/checklists to prevent errors, the current system rewards  “guess work” through multiple choice exams and the art of ‘Pimping’ (especially when the ‘gold standard’ is the ‘Pimper’ and not a referenced source). In a culture where surgical checklists and multidisciplinary teams are the norm – why must the doctor be the pillar of all knowledge that stands alone, unsupported by the vast amount of medical knowledge that is literally at our fingertips?

I dare say that most of us want to train physicians who are humble enough to look things up on our smartphones.  If we want our clinical clerks and residents to know their limits – why must I choose “D” or randomly guess on items I don’t know?  With modern computers, should we not be able to allow learners to say “I don’t know, but I know where to look it up”?  Would that not be a better habit to form?

One recent study (2011) showed that most of our patients are alright with us looking up information (only 9% decreased their confidence level, and only 7% perceived lower quality of care), and we often over-estimate their negative perceptions (MDs predicted 51% decrease in confidence, and 33% decrease in quality of care). This study suggested that younger patients are also savvy about random internet search engine use and negatively responded to such uses of technology (to a significant value of <0.001).

We must be mindful that our hidden curriculum and assessment does not suggest that if you’re a “real doctor” you should just bluff and guess if you’re not sure – lest you risk looking like a fool.  Instead, we need to cultivate a culture that encourages each person to become more self-aware so they know their limits and how to overcome them.

The Value of Knowing you don’t Know

When I ask questions (i.e. ‘pimp’) my students and junior residents, I have always rewarded them for saying “I don’t know.”  I am happy if they are able to recognize that they have their limits of knowledge.  I reward them further when they ask for 2 minutes to look it up because then I can watch them reason through their thinking, vet the course with which they navigate the vast knowledge base of our discipline, and possibly guide them towards the right answer.  In fact, I have used this as a teaching technique, with 4 learners collaborating via smartphone to make a quick learning guide after being posed a question they could not answer.

Some day when I am not there and they are beginning practice, I will feel successful if they retain only that skill of being able to look up and vet the answers in front of them.  This may be through an adjudicated Google search, or Bing, or whatever search engine du jour.  Search engines, you see, are portals to finding further information, and not an end unto itself.  I hope to train savvy enough medical practitioners so that they may click on any link and judge the content that lies beyond.

With the rate of medical research and scientific discovery, I have no doubt that the “medical fact” I teach them now will be vastly out of date and possibly viewed as “medical myth” by then.  The only thing that will allow our learners to continue to change and grow with our discipline will be those skills of point-of-care research and evaluation.

The Future is Ours to Imagine

I dream of a day when we might acknowledge that it is okay to know your limits as a physician, and to seek help when needed.  And that those who know less aren’t shunned for not knowing which drugs cause AKI, because literally you can look that up in about 10 seconds with the right database.  Perhaps, as Erik Venos stated, there could merely be time penalties on exams for using the internet (or pocket books)?  Or perhaps you might even be high-tech enough to capture which sources the test-taker used to see if it was a legitimate or peer-reviewed source?  Perhaps you could even reward those who used better sources and got to better answers, while being time efficient.

The way forward is not necessarily to repeat history.  Let’s challenge ourselves to lead our field into the future instead of regressing into, or merely repeating, the past.  It was not always better “back in the day.”

Teresa Chan HBSc, BEd, MD, MHPE (Candidate), RC Emergency Medicine, Program Graduate*

*Pending FRCPC status, as I have not yet paid any RC dues :D

Peer reviewed by Brent Thoma

Teresa Chan

Teresa Chan

Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan
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  • Brian Buchanan

    Fantastic article with a well composed argument. This discussion needs to take front and center in the realm of medical education, as we (as students of medicine) have put up with much untested presumptions. As noted, this is going to become even more critical with duty hour restrictions and expectations on length of training.

    My only hesitancy with going full steam with this philosophy is that physicians in training (and realistically staff) do need to walk a fine line between,”regurgitated working knowledge” and, “ability to access, critique and integrate on-the-go medical information”. I am simply being the devils advocate on this one, because of course, we still must encourage rigorous study during medical training. One could simply imagine that down the road perhaps a response to any clinical question may be answered by “I don’t know” and “I do not need to know that because I can look that up”. As in my short time thus far as an internal medicine resident (PGY-4 as of today), I have already seen this response spun into action. Therefore, we will need to specify what types of information we consider necessary in our working medical knowledge.

    Going ahead, I think this is where, “Competency-based medical education”, is heading; however, this movement will likely occur at a glacial pace and will need much careful consideration.

  • Teresa Chan

    Thanks @BrianBuchanan for your thoughtful reply. I do agree there are nuances that need to be navigated – there is a vast difference between ‘don’t EVER need to know because I can look it up’ and ‘pretty sure, but still should check’. This is especially so with regards to time-sensitive decisions.

    For instance, imagine an emergency physician who needed to look up evidence-based dosing for medications EVERY time they gave a round of epinephrine or amiodarone. That might be harmful to patient care.

    That said, a general EM physician who works less frequently at a pediatric centre, who gets 1 peds code every 2 years should NOT be faulted for using a Broselow Tape and PALS references. In fact, that is encouraged by the PALS course.

    The precipice between working and semantic memory though needs to be further studied. How many times does a learner need to look up a factoid before it becomes engrained in their head…? For some the answer is one time. For others it is many times.

    Much work to be done still on this!

    TChanMD

  • Pamela Velos

    I can imagine how this I-can-look-it-up reality could lead to physicians becoming irrelevant as other healthcare providers (NPs, nurses, chiropractors, pharmacists, etc) and patients could just as easily look something up to diagnose, treat and monitor. With mHealth apps from credible or adjudicated sources becoming available to do things that MDs have been trained to do will physicians really be necessary?

    I’d like to respond to the three questions posed.

    1)Knowledge is the accumulation of facts, information and experience. The knowledge is used for the physician to take the effective action in creating a differential diagnosis and management plan including tests, patient education, treatment and follow up. You have no power over anyone else including nurses and patients to take effective action based on your advice.

    2)My exams did focus on difficult clinical reasoning. I too wonder why yours didn’t.

    3)I’m wondering why you feel you have to negotiate with nurses so much? When I’m a patient I want a doctor who listens and pays attention to what I am saying, and gives advice -which I am free to take or not – based on their knowledge. I don’t want someone who is always looking at their smart phone. I don’t mind if they take a moment to look something up, after they’ve told me that’s what they’re doing.
    In my practice I need to look things up occasionally or if patients want to look things up I will look it up with them and use it as a teachable moment. Usually when I tell them something and the internet confirms it, the patient is more likely to be adherent to the advice I am giving – they believe I know what I’m talking about.
    It’s important to note the knowledge is in my head and the internet confirms it – I don’t have to look it up first.

  • Teresa Chan

    Hi Pamela,

    Thanks for your thoughts.

    I disagree with you that it is our knowledge base that sets us apart from NPs, RNs, Pharmacists. I believe, actually, that it is our diagnostic reasoning and thinking process. We are usually trained in the deductive model (Having and approach, Gathering Data, Excluding unlikely diagnoses, Developing a DDx, and then arriving at a possible solution) – more Type 2 thinking. The traditions in other disciplines is around experience and pattern recognition – more Type 1 thinking. Inevitably, MDs do pick up the Type 1, but it is not the primary set point for most of us when we are first trained.

    It is my fear, too, that if we do not become more clearly ‘branded’ in our training that our job may become more obsolete. We clearly cannot keep up with the knowledge mass that is accumulating.

    This is especially why we need to train learners to be better information managers. Because, as you point out, there is little that sets us apart when we can no longer cope with the sheer volume of information that would be the underlying knowledge base.

    With regards to your answer, I must say, they are very interesting to me as someone interested in the social studies-side of medicine.

    To share with you my perspectives, I will analyze your responses a bit:
    1) “You have no power over anyone else including nurses and patients to take effective action based on your advice.” – I think that with movements like the CanMEDs and ACGME competency frameworks we are moving away from ‘I am physician, and do as I say’ model. Throughout my training, I have been taught to respect my patient as a fellow collaborator, someone with their own values and decision-making ability. My role is to guide them when they seek help – not to control them to do my bidding. The same, if not moreso, of our nursing and allied health colleagues.

    2) My exams DID focus on clinical reasoning – but with relatively clear cases. Our oral exams are better for this (but I have signed a confidentiality waiver that prohibits me from going into details). That said, cases on exams ALWAYS have answers because of they way they are designed. What I think would be interesting would be to provide *difficult* diagnostic dilemma and reasoning scenarios to push candidates in the setting of uncertainty and see how they respond. Again, maybe not feasible, but as I stated the future is ours to imagine.

    3) I think that any doctor that needs to look at their smart phone during a conversation with a patient may need help with interpersonal skills rather than knowledge… :D I think that is great that in your stage of training and at your skill level you no longer need to look things up. But we are in a generalist specialty that borrows from MANY other sources of literature… and sometimes you can’t possibly know it all in the most up-to-date way.

    Currently, as I just wrote my exit exam, I am very up-to-date on my knowledge. On most days that is the case with myself as well. Mostly the internet confirms my thinking. In fact most of the times I have found myself looking things up are with unusual cases – like the heart transplant patient who is in SVT – Do they need a lower dose of adenosine? (I thought the answer was yes, and by George I was right!) Sometimes it is to confirm the landmarks for a not-often-used nerve block, or to confirm the dose of valacylovir.

    Beyond that, I don’t often NEED to negotiate with nurses anymore. That’s because I have a track record with them and have earned their respect. The question was meant to highlight the need for doctor-patient & multidisciplinary collaboration – one of the CanMEDs roles. Currently our exams focus almost purely on ‘medical expert’, but my job requires a fair bit of most of the ‘intrinsic roles’ too (i.e. Communicator, Collaborator, Scholar, Manager, Health Advocate, Professional).

    Traditionally, we have emphasized the MD-patient role, and now our learners are well versed at this. But interpersonal skills must extend beyond just the patient. Good communication, great collaboration, professionalism and adequate managerial skills are what reduce human-factors errors in our system.

    We have an evolving culture around crisis resource management for critical scenarios. Our nurses are very empowered by most attendings to speak up if there are noticeable problems that affect patient care – sometimes this means they catch our mistakes. We have even taken this to the next level, with some of our MDs leading the way with “in situ” simulation scenarios that are building that culture. Most recently we had a scenario based around when RNs should should get the attending when a junior resident is out of their element. Similarly, when I run codes, I always pause, summarize and work through my H/T’s and thinking process out loud so that others may chime in with suggestions. And most importantly, with the never ending chess game of moving patients around so they can all be in the adequate level of care, it is often the bed managers and charge nurses with whom I work in order to accomplish these feats. Around this if there is a difference of agreement, then that is when I need to negotiate.

    If we were in a culture of top-down rank-and-file MD oppression, such scenarios would not occur, it is true. I would just pull rank on my colleagues and never have another conversation where I was wrong. However, patient care must also extend beyond the boundaries of a doc’s ego, and I truly believe that multidisciplinary care actually enhances the patient experience.

    Again, thank-you for your comments! I think it is important for us to have these discussions that we have behind closed doors and move them to out in the open. Yes, you will see, as a Milennial I am also one of the first ‘generations’ of docs that have ‘Grown Up CanMEDs’ (i.e. completely trained after the release of CanMEDs in 2003). I think in retrospect, we will see that this was a momentous shift in the way physicians view themselves.

    I have only EVER drunk the kool-aid, some say, but I truly believe the way forward is not purely in our expertise.

    TChanMD

  • http://manuetcorde.org Eve Purdy

    Dr. Chan,

    Thanks for writing a great piece. Having just finished preclerkship I am used to assessment and memorizing factoids. Are the topics that we have covered in preclerkship necessary? Absolutely. Will I need to know them? You bet. Do I know them as well now as I did on test day? Regretabbly, no.

    The hardest assessment that I have been subject to during preclerkship was not an exam or OSCE. It was an open-book, group assignment to work through a case. Sounds easy right? Wrong. It was a hard case that forced us to push the knowledge that we had beyond where we felt comfortable. It forced us to take into account a huge amount of information, process it, then use outside sources to help develop a plan. Our group struggled, we got the answer wrong. We learned.

    Recognizing one’s own limitations, asking the right questions, then making attempts using appropriate resources to answer those questions is what being a learner is all about.

    I’ll definitely be doing a lot question asking when I start clerkship in September but I don’t see why the above model has been traditionally left to early learners. The number, nature and types of questions will vary throughout my training and practice but I hope that I’ll always remember the curiosity, enthusiasm, desire to do good by patients and humility necessary to be a good medical student.

    Thanks for your call to change.

    Eve

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  • MJ King

    As one of those “dinosaurs” who remember books, I am frequently frustrated by the lack of basic medical science knowledge displayed by the students and residents I supervise. I agree that the entirety of medical knowledge is now so large that it won’t all fit into one head but I also believe that there is a core body of knowledge without which one cannot expect to be able to reach those rationally derived clinical decisions that will benefit the patient, knowledge that should reside in one’s own brain. One of the issues I had with my own medical education was that most of our teachers were sub-specialists in one field or another, usually not teaching, and would often cover their own interest in more depth than the average medical student needed then gloss over the rest of the field. For example, did we really need a whole semester on gout? The other issue I found, though was thankfully able to avoid by entering medicine via nursing, was the isolated learning of facts without a “big picture” framework in which to place these factoids. So when we came to the gout lectures it was difficult for the newbie to know what was important and was what the prof’s ruminations on his first love. I don’t have a clean-cut solution but the “I’ll go look it up” thing, while valuable, is not always available in the heat of (clinical) battle.

    • Teresa Chan

      Hi Dr. King & future-Dr. Purdy,

      Thanks for joining the discussion!

      It’s exciting to have the chance to have these discussions and have it hosted by BoringEM.

      I think your two points are actually quite complimentary, so I’m going to editorialize by stating that you are both right. And one-sized-fits-all expectations of learning are probably being left at the wayside.

      Eve: I think there is something to be said about learning through a case-based approach (as I hail from McMaster University, one might expect so). I think cognitive psychology has proven that students often learn better when making interconnected links. It has also, however, proven that test-retest is very good at engraining things in memory as well.

      Dr. King: I think your point is well taken that “I’ll go look it up” is not a great place to be when you’re leading the charge in a ‘clinical battle’. I think if the expert clinicians of the group were to stop and look things up every time… that would truly paralyze the system. If every emerg doc needed to look up the dose of epinephrine during a code, well… that would be not ideal.

      That said, I’m sure we’ve all forgotten tidbits (What’s the pediatric dose of gentamicin again??) and when we do it’s worth role modeling the use of adjudicated sources to our learners. Beyond that, it is also worthwhile to consider how ‘knowing when to look it up’ is possibly a key skill. In 2007, the famous MedEd Gurus Drs. Kevin Eva and Glenn Regehr wrote about this concept. [Acad Med. 2007;82(10 Suppl):S81–S84.] Theirs is an experimental design, but the presented data is pretty convincing that when you don’t know, determining that you should look it up is probably somewhat of a skill. This may explain such phenomena we see on the wards – in days gone by, learners who did not know would viciously jot notes down and then run to the library to study after hours. Meanwhile, now, they probably take a moment – look it up – and then join back into the conversation/discussion, slightly more informed and possibly incrementally smarter. And maybe, after they do enough, they won’t need to do this anymore…. or at least as often.

      WHAT DOES THIS ALL MEAN?
      Yes, I think you are both right. Learners need to learn more. Whether that is by PBL, or at didactic sessions, or while being ‘pimped’ a la Socrates. But they are still learners… And are entitled to some time learning. It’s just tough sometimes when they do it in front of us as teachers… but if patients are on the line, then if they have time, then I do believe they should (quickly, efficiently, and efficaciously).

      What it does mean is that, as teachers, maybe now we can actually very quickly assess how confident or competent a learner is just by looking at how often they look things up. And what is the answer/question when they do? Are they asking about nuanced problems (i.e. evidence behind ASA+Plavix vs. ASA alone for stroke in the latest trial?) or “should know” material (i.e. What is a stroke?)

      These moments can be seen as a window into their learning – and if you’re an Emerg Med (EM) educator, well, you’re usually not very far away. Login after them and look at the browser history – see what they looked up! Did they look up a ‘good’ or a ‘bad’ source? Did they download a paper?

      Beyond that does it take them an inordinate amount of time to look something up? If so, they maybe the conversation needs to be about situational awareness. Maybe an in depth literature review is not best done at work, on the fly, and that *asking* for help from someone who DOES know (e.g. the attending) is *appropriate* at that point. Rather than ‘toughing it out’ maybe it is best if everyone ‘slugs it out together’.

      I’d love to hear more, of course, of your learning experiences in nursing! What/How was it different?

      TChanMD

  • http://ermentor.com Nadim

    interestingly that author is a program director – it seems a little unsympathetic and a poor choice of words. Perhaps he has been colored by a couple of interactions with failing learners? or perhaps ones that didn’t seem to share his passion for IM? Javier Benitez recently Tweeted a nice article on the approach to “problem learners”.

    Truth is the generation gap does make faculty uncomfortable and we wrongly assume the methods we were exposed to were better.

    That’s not to say that we don’t value your needs – we tend to default to knowledge that we feel is important and sometimes our passion gets in the way. Clinical teaching is a double edged sword in this regard. You get to learn from my experience, but there’s personal biases thrown in there too – and we are all different in our approach. I’m [don't tell my wife] a nerd. i feel “why wouldn’t you NOT want to know all that neat stuff?”. I enjoy knowing stuff – I simply want the same for you.

    It is clear from the dialogue that it takes a lot to become an effective clinician. BUT Designing exams and assessment tools for the non-medical expert CanMEDs Roles takes, creativity that comes from educational expertise and time -all of which are in short supply . we default to what we know best – pimping you on what we know at the bedside and on paper.

    But we are changing as we learn more how to teach and evaluate learners [As Jason states, the exam IS changing to reflect more reasoning and less Rosen's lists] and we are changing the way we write the CITE to reflect this as well as how we evaluate the non-medical expert roles.

    your advocacy is good to hear. It’s what helps us wake up and change our approach. Perhaps we need a more millenial slogan “Don’t hate! Evaluate!” hah? no? oh well i tried …

    thanks

    Nadim

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  • david

    Thank you Teresa for your article. About “googling” of all of us, itis like making a fire once you are stranded in a remote area and you are craving for a warm place. Are you going to screw up your face after lighting a fire made with stinky camel dung? No, I don’t think so. I think the same about internet sources of the information. If you know something about the reliability of your source, there are no downsides in googling. Please, keep on posting your articles….

  • http://www.incontrarian.com/ Joshua Alvarez

    Teresa, cool post. Especially liked the “Bigger-brain” syndrome part. Linked you onto my website, InContrarian.com, which covers millennial politics/culture.

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