Hackschooling Residency Education

By Nadeem El-Kouri, MD, and Brian Milman, MD, on behalf of the SAEM Education Committee

The Current System

Current graduate medical education usually revolves around a didactic framework designed as a one size fits all model in which learners are expected to conform to the pace and educational level of the rest of the cohort.

Classically, residents attend a weekly conference that minimally considers their existing knowledge and proficiency on the subject. For the average learner, this approach is not a significant issue as the system is catered to the average. The above average learner is often not challenged by formal curricula. They are left to find opportunities to challenge themselves as the system functionally neglects them; unfortunately, limited free time outside of residency makes this difficult to accomplish. In contrast, the below average learner will likely be overwhelmed with the proficiency gap and the disparate performance of their peers. Depending on the magnitude of their deficit they may start residency with few true opportunities to progress, further solidifying their limitations.

As medical schools and residency programs increasingly consider moving towards curriculums based on entrustable professional activities (commonly referred to as EPAs) it is important for residency programs to consider a similar, more customizable educational framework. This strategy engages students at their specific spot in the journey of proficiency regardless of where they fall on the spectrum. This approach allows for more focus on the individual learner’s proficiency and goals.

What is Hackschooling?

Originally coined by the homeschooling family of the then 13-year-old Logan LaPlante at his TEDx talk in February 2013, the term was used to refer to hacking one’s own education. Though many may have a negative impression of hacking, at its core, it confers a sense of creativity and going outside the established norm to find answers to problems. Even in the most negative light, a hacker must have an extensive understanding of their subject. This in-depth comprehension begets the creativity that makes life-hacking so appealing. It does raise the question, “why can't this be applied towards the medical education model?”

Medicine

The medical profession prides itself on a culture of lifelong learning which requires us to take charge of our own education post residency. This is no longer just the mark of a good physician, it has become a requirement to stay relevant and practice safe medicine in the era of an ever evolving practice landscape. This necessitates high degrees of curiosity, self-awareness, motivation, and drive. It is not feasible to expect people to spontaneously demonstrate these qualities upon graduating residency after being spoon-fed high yield/necessary information for all of residency (and arguably medical school). Just as in sports, you should practice how you intend to play. These are characteristics which are honed through repetition.

A Logical Application

Lifelong learning requires self-awareness to identify knowledge deficits followed by identification of ways to fill gaps. When learners are exposed to a regimented curriculum throughout residency, adjusting to post-residency learning is difficult. Our goal should be to help train the habits which make successful physicians. Self-directed learning is a crucial aspect of that. A hackschooling approach offers learners more control over their own education allowing them to direct their focus to what they need most.

Such a curriculum also allows people to explore interests within the specialty. Many residency curriculums do not have flexibility to allow subspecialization or exploration of possible fellowship interests due to staffing needs within a department, commitments to off service rotations, etc. A customized and interactive educational journey afforded by hackschooling allows learners to go deeper into topics that they may otherwise have had minimal exposure to in the current framework. This approach also has the potential to engage learners as they are being stimulated and pushed in ways that are meaningful for them.

The pre-residency experience is so unique for each resident that their educational and experiential foundation cannot be assumed to be the same from resident to resident. This is the assumption with a predefined residency curriculum, and it is a faulty one. Even the examples above regarding the average learner is an oversimplification. There are so many subdomains that demand proficiency to be a competent physician. The average learner is almost never truly average in each subdomain. Each person is heterogenous amalgam of these subdomains.

It is more efficient and interactive to provide an educational framework that adapts to the learners needs, meeting them where they are and engaging their interests. Despite attempts within the first few months of residency to homogenize learners’ competency their unique pre-residency experiences ultimately make this challenging, inefficient, and increasingly impractical. Hackschooling allows residents who excel to continue to grow regardless of their skill. Instead of a standardized model where students may be throttled and other students may be pushed to aggressively, facilitating burnout, such a customized curriculum allows all learners to grow simultaneously.

Progress

These ideas have already permeated today’s graduate medical education. The Accreditation Council for Graduate Medical Education (ACGME) currently classifies asynchronous learning as a core didactic activity. This sanctioned opportunity encourages learners to engage with the countless available resources at their own convenience.

There are even widely utilized emergency medicine curricula which list multiple types of learning resources (podcasts, FOAMed articles, textbook references, journal publications, etc.) for a given topic. These options give learners the chance to select resources best suited to their self-identified learning style.

Additionally, some programs set aside time in weekly conference for resident directed topics. Just-in-time learning of this nature dedicates time to delve into topics which residents have mentally bookmarked but have not been able to pursue. Another example includes an updated journal club. In addition to literature review, some institutions encourage residents to select a resource from the FOAMed sphere, including podcasts, blog posts, etc.

These strategies help residents navigate through the self-reflective nature of learning, briefly explore a few resources on the subject, and select one based on their interests. While the above examples demonstrate progress, these principles are far from mainstream and there are abundant opportunities for further improvement and innovation.

Conclusion

The existing system is designed to meet a minimum competency instead of allowing for continued growth and support for all learners. Residency should be focused on not only graduating well rounded, competent physicians, but on helping them to develop the habits to continue to learn and grow as a physician and person. Hackschooling provides ample opportunity to ensure not only that minimum competency is met, but also that they are prepared for the rest of their careers.

About The Authors

Dr. El-Kouri is a PGY3 and chief Rresident in the Department of Emergency Medicine at the University of Oklahoma in Tulsa, Oklahoma.

Dr. Milman is an assistant professor of emergency medicine and associate residency program director at the University of Oklahoma School of Community Medicine.