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Explore This IssueApril 2019
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My nephew is an addict. These words do not come easily to me, but I have come to accept them as true. In retrospect, I should have recognized the telltale signs: He stopped picking up the phone when I call. He disappears and then re-emerges hours later, seemingly having done nothing. He has lost interest in leaving the house and keeps talking about friends I never seem to meet.
My nephew is addicted to Fortnite.
For the uninitiated, Fortnite is a multi-platform, multi-player video game, in which you and your team parachute onto an island. As with many video games, the object is to shoot anything that moves. Unlike many video games, however, you are fighting the clock; during gameplay, there is an approaching storm, which gradually limits the territory in play.
Fortnite has been compared by behavioral psychologists with heroin. There is Fortnite rehab. Divorce filings have started to cite Fortnite, by name, as a cause.1 When gamers are not playing themselves, they watch other people play. And they pay for the privilege: Tyler Blevins, better known to his fans as Ninja, earned $10 million in 2018.2 He earns $500,000 per month from subscribers to his streaming service. I’ll say that again: he earns half a million dollars each month from aficionados who pay to watch him play. A video game.3
From a purely scientific standpoint, one can’t help but admire what Epic Games, the creators of Fortnite, hath wrought. Fortnite is not Pac-Man. To play, one must master an arcane set of rules and reflexes. This takes time and effort. To date, 200 million players—mainly school-age students—have elected to learn this complex skillset, on their own, without the nagging that usually precedes learning at that age.4 Wouldn’t it be amazing if technology like this could be co-opted to teach something, well, you know, useful?
Teaching with Technology
Pac-Man is to Fortnite as the traditional classroom lecture is to a Massive Open Online Course (MOOC). We are all familiar with the traditional brick-and-mortar classroom lecture, with PowerPoint slides at the front of the hall and students gently dozing at the back. The one thing that all of these lectures have in common is that all stakeholders—lecturers, small group leaders, students—are all physically present. The MOOC does away with that last requirement. Instead, lectures are taught virtually, through live streaming or recorded lectures. The sense of community is preserved through remote question-and-answer sessions, group projects and other assignments.5
The MOOC is a cornerstone of a revolution in education in which your educational experience need not be dictated by your institution. Instead, you can pick to attend the classes that best suit your needs and interests, regardless of where the lectures may actually be taking place. By October 2013, the company Coursera had registered over 5 million students for MOOCs.6
The MOOC is a cornerstone of a revolution in education in which your educational experience need not be dictated by your institution. Instead, you can pick to attend the classes that best suit your needs & interests, regardless of where the lectures may actually be taking place.
There is no true MOOC in rheumatology, but we are getting there. ACR Beyond, the new streaming service developed by the ACR to allow members to attend conferences virtually, also has the ability for remote attendees to ask questions of the lecturer; this level of interaction was not available with the former platform. The online journal club, #rheumjc, was founded by Paul Sufka, MD, Chris Collins, MD, and others. It has many of the characteristics of a MOOC: There is a common point of discussion, it is interactive, and participation is not limited by geography. Take either online structure, and add on group assignments, tests and course credit, and you would get a little closer.
The potential for a MOOC to revolutionize teaching in a field like rheumatology—a series of disparate subspecialties loosely connected by a common love for prednisone—is extraordinary. I could give a lecture on psoriatic arthritis, for example, but it would be like me singing falsetto: I could do it, but not well, and I would be relieved when it was over. I would, however, be delighted to field your trainee’s picayune questions about granulomatosis with polyangiitis and microscopic polyangiitis, especially if I could talk someone like Christopher Ritchlin, MD, MPH, at the University of Rochester or William Rigby, MD, from Dartmouth into giving the talk on psoriatic arthritis for me.
Now imagine a weekly seminar in which these talks would be followed by a talk on pregnancy and rheumatic disease, given by Megan Clowse, MD, at Duke or Eliza Chakravarty, MD, at the Oklahoma Medical Research Foundation. Perhaps the lecture on myositis could be given by Andrew Mammen, MD, PhD, from the National Institutes of Health or Chester Oddis, MD, from the University of Pittsburgh. Getting all of these experts to fly to a single institution, week after week, to give a single talk, would be impossible. Getting them to all teach in the same MOOC, however, is eminently doable.
MOOCs, of course, are faced by the same problems that affect brick-and-mortar institutions. For example, being able to attend a lecture in your boxers, apparently, does not increase the likelihood that you will show up; proximity and peer pressure help ensure that students show up to a lecture in a way that is difficult to replicate remotely. Another problem with MOOCs is the first O: By tradition, these courses are a public service, freely available to all. The infrastructure required for a MOOC, ranging from web platforms to lecturers, is not free, and no one has completely figured out how to make these services profitable. Still, especially for education in rare diseases, the MOOC may eventually prove to be an important advance.
The Gap Between Seeing & Doing
The problem with the sold medical education mantra of see one, do one, teach one, is that it glosses over the often painful journey between the first and second parts of that phrase. As William Osler, MD, said, “Medicine is not an inheritance.”7
Surgeon and writer Atul Gawande, MD, MPH, put the issue more succinctly: “Like everyone, [physicians] need practice. That’s where you come in.”
He elaborates: “In surgery, as in anything else, skill, judgment and confidence are learned through experience, haltingly and humiliatingly. Like the tennis player, the oboist and the guy who fixes hard drives, we need practice to get good at what we do. There is one difference in medicine, though: We practice on people. … [T]here have now been many studies of elite performers, … and the biggest difference researchers find between them and lesser performers is the deliberate amount of practice they’ve accumulated.”8
Ten thousand hours. The commonly repeated mantra is that it takes 10,000 hours of practice to become an expert at anything.9 The lay public just doesn’t realize that their physician may be providing their care before that landmark has been reached, and to be honest, physicians are often a little squeamish to describe this process of medical education in any detail.
It is quite possible that patients benefit from this process. They benefit from this process indirectly, because if we never trained new physicians, no one would be left to replace those who had retired. They may also benefit from this process directly; plenty of data indicate that patients seen in teaching hospitals have better outcomes.10 Presumably, this is due to the environment of questioning and re-exploration trainees create.
Despite this, opinion is growing that we should make better use of non-patient resources to teach some of the practical parts of becoming a physician.11 Actors (and manikins) posing as patients are already standard; some of you may have first learned how to perform an arthrocentesis on an artificial joint or a cadaver, for example. But wouldn’t it be great if there were better shortcuts between seeing and doing?
The Virtues of the Virtual
The business world has already begun to embrace the potential of virtual reality for the education of their sales force. Walmart, for example, has purchased 17,000 virtual reality headsets so employees can experience, firsthand, the horror that is Walmart on Black Friday. A facilitator guides participants through the simulation, so they can ask questions about what they are experiencing. What they are experiencing is pressure: The simulation is meant to be as realistic as possible, so every sales associate can be optimally prepared for the big day.12
If only medical training were this advanced.
This is not to say that advances have not been made. Virtual reality modules have already been developed to teach empathy. One company has used virtual reality to place the user in the eyes of a terminal patient, breathing his last breath, so care providers can develop a better understanding of the process of dying from the viewpoint of the patient and the patients’ family.13
Clearly, this is only the beginning. The potential of virtual reality to teach trainees about rare diseases makes the mind salivate. The problem in my clinic is I rarely have a patient with a subclavian bruit show up on the same day that a trainee asks me about Takayasu’s arteritis. On other days, I may tell a trainee: you’re lucky you’re here today; this patient has cutaneous polyarteritis nodosa. You’re never going to see something like this again. I’m sure that the same words have passed your lips at some point, as well. If you think about it, however, there is a certain tyranny that ties medical education to this sort of happenstance.
Now, picture a scenario in which a trainee could don a pair of goggles and see the discordant eye movements associated with an orbital pseudotumor or hear the prolonged wheeze of subglottic stenosis. It may not be as good as having an actual patient at the end of the stethoscope, but it would be a good deal closer to that experience than the descriptive passage that appears in UpToDate.
To my mind, this does not seem all that farfetched. Technology has already been used to convince 200 million players they are parachuting onto an island infiltrated by enemies; the same technology convinces 200 million players to go through this same scenario, again and again, without tiring of it. It seems like not much of a stretch to think the same technology could be used to enhance the game-like aspects of learning and use our inherent need to play as a tool to promote learning and knowledge retention.
They say you can’t teach an old dog new tricks. Then again, they’ve never tried to introduce that dog to Fortnite.
Philip Seo, MD, MHS, is an associate professor of medicine at the Johns Hopkins University School of Medicine, Baltimore. He is director of both the Johns Hopkins Vasculitis Center and the Johns Hopkins Rheumatology Fellowship Program.
- Feeley J, Palmeri C. Fortnite Addiction is forcing kids into video-game rehab. Bloomberg. 2018 Nov 27.
- ‘Ninja,’ the Fortnite streamer who’s one of video gaming’s biggest stars. CNN Wire. 2019 Jan 1.
- Chalk A. Fortnite streamer Ninja makes $500,000 per month. PC Gamer. March 2018 Mar 19.
- Fingas J. ‘Fortnite’ now has over 200 million players. Engadget. 2018 Nov 27.
- Friedman J. 10 things to know about MOOCs in online education. U.S. News & World Report. 2016 Dec 20.
- Thayer WS. ‘Osler the teacher’ in Osler and Other Papers. Baltimore: Johns Hopkins Press/ London: Humphry Milford, Oxford University Press, 1931.
- Gawande A. The learning curve. The New Yorker. 2002 Jan 28.
- Simon HA, Chase WG. Skill in chess: Experiments with chess-playing tasks and computer simulation of skilled performance throw light on some human perceptual and memory processes. Am Sci. 1973 Jul–Aug;61(4):394–403.
- Burke LG, Frakt AB, Khullar D, et al. Association between teaching status and mortality in US hospitals. JAMA. 2017;317(20):2105–2113.
- Scales D. Opinion: In simulation era, your doc’s first try at a procedure should not be on you. WBUR. 2016 May 6.
- Sisson P. In Walmart’s virtual reality simulation, Black Friday never ends. Vox. 2018 Nov 15.
- Burge K. Virtual reality helps hospice workers see life and death through a patient’s eyes. NPR. 2018 Dec 27.