Evidence-based nephrology-rheumatology debates: a novel educational experience during nephrology fellowship training

Abstract

Medical educators have called for novel learning methods that supplement the traditional lecture format. Fellowship education involves didactics and pedagogic strategies using a variety of learning tools in order to improve critical thinking skills. Debating is one such tool that can enhance critical thinking skill. However, to the best of our knowledge, evidence-based debating among two different internal medicine subspecialty fields during fellowship training has never been reported. In this article, we describe an innovative educational experience for trainees using the evidence-based debate format. Two teams consisting of equal number of first- and second-year nephrology and rheumatology fellows participated in our annual interdivisional debate session. Topics that have been debated over the last three annual debate sessions include management of small vessel vasculitis and lupus nephritis. To assess the educational experience of the debate session, all fellow participants were asked to complete an anonymous on-line survey following the debate. The survey consisted of several questions using a 5-point Likert scale. All fellow participants enjoyed the debate format and found this experience to be thought-provoking and to enhance their self-directed learning.

• Debates during nephrology fellowship training
• debates in medicine
• evidence-based learning in medicine
• innovative educational tools in nephrology
• nephrology education
• nephrology-rheumatology debates

Introduction

Innovative teaching methods can create an environment that might promote interest in nephrology among medical trainees. Such teaching methods might also be useful in maintaining enthusiasm and enhancing satisfaction for nephrology amongst fellows during training. At our institution, we have developed several novel teaching tools in nephrology.1–4 We are hopeful that these tools will not only increase interest in nephrology but also enhance education and training of nephrology fellows. To promote more collaborative fellow–fellow and faculty–fellow discussions in a lively enjoyable manner, we embarked on another novel educational session. Since the last three years, we have conducted annual combined nephrology and rheumatology debate sessions involving both faculty and fellows. In this article, we describe “Evidenced-based Nephrology-Rheumatology Debates” as a novel educational experience during nephrology fellowship training.

Evidence-based debate session

Pre-session preparation

A. Role of faculty

One month prior to the debate session, one designated faculty member from each division decide on a controversial topic to be debated. Both of these faculty members also moderate the debate session. Fellows from both the divisions are randomly and equally divided into two opposing teams. A team captain is assigned to each group. A faculty adviser is also assigned to each team for guidance and preparation for the debate. Each team is assigned a clinical scenario with a management dilemma. For example, the topic that was selected for our last debate session was induction therapy for anti-neutrophil cytoplasmic antibodies (ANCA) associated vasculitis. One team was assigned to advocate for cyclophosphamide as the better induction agent for this condition, while the other team was asked to oppose this agent with another one, rituximab. The above information (meaning names of team members, team captains, faculty advisers and the assigned topics) is then subsequently sent out to all nephrology and rheumatology faculty and fellows via e-mail. Fellows are encouraged to prepare for the debate after reviewing the existing literature on their assigned topic. After the initial e-mail, both faculty and fellows are reminded about the debate session on a weekly basis prior to the debate.

B. Fellow preparation for the debate

To prepare for the debate, each team captain communicates with their team members via e-mail and assigns each fellow team member a subtopic that needs to be researched prior to the debate based on the fellow’s preference. This initial communication occurs approximately three weeks prior to the debate. Each fellow is responsible for researching and preparing the arguments for their assigned subtopic. The two team members educate other team members through e-mail, review relevant articles, discuss counterpoints and identify areas of weakness that need further investigation. Each team meets at least once prior to the debate to review their arguments and order of their presentations. The team captains will seek for assigned faculty member’s advice as needed prior to the debate.

Debate session

The debate sessions usually last an hour. These sessions are held in a large conference room to accommodate fellows and faculty from both divisions. The two teams are seated facing each other. The audience which comprises of mainly faculty members sits around the teams. The moderating faculty member introduces the team members and the topic to be debated to the audience. The debate is divided into several parts. First, each team spent approximately 5 minutes providing introductory comments. Then, assigned fellows from each team review the efficacy, clinical outcomes and safety profile of their drug being debated based on existing/published literature (15 minutes for each side). This is followed by rebuttal comments made by opposing team members (10 minutes). The moderating faculty member ensures that this occurs fairly and appropriately. Finally, concluding statements are made by the team captains (5 minutes). The final 10 minutes was devoted to questions or comments from faculty members in the audience.

Post–debate survey: Acceptance by participants

To assess the value of this tool, an anonymous on-line fellow survey was conducted soon following the last debate session. Using a 5-point Likert scale, the fellows were asked to assess the impact of these sessions on self study, looking into primary data, and usefulness in day-to-day practice. The fellows chose on average a score of 4 out of 5 (5 being extremely helpful) when asked about the debate session facilitating them personally looking up primary data on the topic debated, and helping them to better care for their patients with lupus nephritis and ANCA vasculitis. An average score of 4 was also noted for these sessions allowing them to improve their self-study techniques. A score of 3.5 was noted for these sessions allowing fellows to improve their team building skills. All fellows reported finding the activity highly enjoyable. They also agreed that it enhanced their knowledge and that they would want to use this tool for other topics in nephrology. We found similar excitement and support from participating faculty members.

Discussion

Medical educators have called for innovative teaching methods and materials to supplement the traditional lecture format. Conducting debate sessions created around clinical questions is a learner-centered approach of teaching. Although debating is not commonly reported in internal medicine residency or subspecialty fellowship training, other health-related training programs such as nursing, dental and pharmacy have utilized this teaching tool for educating their trainees.5–8 Critical, reflective thinking is an essential element in patient care and other core competencies of postgraduate medical training. Debating is one such tool that may enhance critical thinking and communication skills.5,6 The debate format has also been used to teach medical trainees complex topics like health care reform and health economics.9,10 Controversial topics in medicine can also be taught using structured debates.11 This can also result in increased comfort level of trainees in discussing certain controversial topics in medicine with their patients.11 Koklanaris et al. have shown higher test score among residents who prepared and participated in a debate as compared to traditional lecture format.12 In this study, trainees who prepared and participated in a debate were also shown to retain their knowledge better than those who attended a lecture.12 Evidence-based debates may provide a unique learning experience during medical residency and fellowship training. Medical trainees can improve their self-directed learning skills by researching medical literature, preparing logical arguments, differentiating between subjective and evidence-based information. In addition, they also learn about actively listening to other perspectives, asking appropriate questions, integrating relevant information and formulating their own opinions based on evidence. Fellows-in-training tend to read medical literature pertaining to their own specialty. Hence, a well-structured debate among various medical subspecialties can also enhance evidence-based knowledge of trainees in other related fields of medicine. This educational tool also fulfils several of the Accreditation Council for Graduate Medical Education core competencies including medical knowledge, practice-based learning and improvement, interpersonal and communication skills and systems-based practice. We believe that the debate-based style of learning not only encourages trainees to participate, but also promotes communication and collaborative skills. This tool creates an interactive learning environment that leads to informative discussions among team members about the appropriate management of the clinical scenario. Hence, this enjoyable educational tool enhances the management skills of both fellows and faculty. The debate-based format can also be used to increase knowledge and interest in nephrology during medical residency. Conducting debates at national meetings among trainees from different institutions may also be a unique and rewarding experience. We plan to use this tool to teach other aspects of nephrology and internal medicine. We encourage all medical educators to consider this interactive teaching tool in their respective field of medicine.

Summary

Debate is an enjoyable learning tool that can be easily adapted to any field of medicine. From a pedagogical perspective, this method allows for a balance of teaching such that both analytical and non-analytical reasoning in medicine are utilized simultaneously. Our findings suggest that novel ways of providing nephrology education using methods, such as evidence-based debates described above may allow fellows to learn more effectively and help keep them satisfied and engaged during training.

Declaration of interest

No conflicts of interest.

Acknowledgments

Dr. Hitesh H. Shah is the Director of the Nephrology Fellowship Program at the Hofstra North Shore-LIJ School of Medicine. Dr. Kenar D. Jhaveri is the Internal Medicine Clerkship Director at the Hofstra North Shore-LIJ School of Medicine.

We thank Dr. Diane Horowitz (rheumatology attending) for her assistance in organizing the debate sessions. We also thank all our fellows for preparing and actively participating in the debate sessions. Part of this work was presented at the American Society of Nephrology (ASN) Kidney Week 2012 in San Diego, California.