Flipping the Medical Classroom & New Hypertension (HTN) Guidelines – MedCram Interviews Osmosis

Flipping the Medical Classroom & New Hypertension (HTN) Guidelines – MedCram Interviews Osmosis


thanks everyone for joining us I am
privileged to have dr. Rishi Desai on he is a amazing amazing clinician and
amazing educator well let’s start with the clinician part first first of all
he’s a pediatric infectious disease specialist at Stanford University but
even more importantly our Rishi you were as far as I’m concerned one of the
stalwarts and the pillars of flipping the classroom on YouTube and on the
internet because you worked with khan khanacademy tell us a little bit about
that yeah thank you for inviting me Rajat it hang out with you a bit I
started there because I was excited about kind of making online tutorials
making videos and I started doing that with them mostly around kind of pre-med
topics and and they kind of got into MCAT so getting kids into into Medical
School and I loved doing it and then about three years ago I switched over to
osmosis and continued kind of helping to make videos but but now I have moved
roles so now there’s a whole team of folks that make videos and and I just
love doing it’s a lot of fun I think the problem today has been is trying to
figure out what information do we need to know and what information can we just
look up what do you think yeah no I I couldn’t I couldn’t agree more and in
when I have fellows and residents with me now I care more about who has the
best question than who has the best answer and what I mean by that is like
you know you walk by a patient who’s on dialysis and if you don’t even think to
question how that affects their medications because now that the meds
are even dialyzed off if you don’t even think to ask that question then you’ll
never even think about Reed dosing their medications but if the question pops up
in your head then you can easily go look up or talk to a pharmacist about kind of
figuring out how to read dose of medication so I think the best doctors
are the ones that are kind of coming up with the right questions and thinking
about things and then the easier part is then going to look things up I remember
becoming a third year medical student I mean I’d be getting up at 5:00 6:00 in
the morning going in doing rounds coming home at 5:00 exhausted and then
realizing that I still have to study and you’d look up the syllabus and they’d
say okay here’s Harrisons right I mean it’s like a doorstop one of the things
that come up recently here in in the media it
has been the new hypertension guidelines and I think it’s a a great example of
all of the issues that are plaguing medical education for instance they
always used to tell us we’re teaching it here in medical school but we’ll have to
tell you up front 50% of what we’re teaching you is wrong we just don’t know
what 50% it is and here we have the new hypertension guidelines yeah exactly and
I would love to hear your take on them because I think these guidelines get a
lot of play on Facebook and Twitter and things like that but but it’s good to
dive into and understand kind of what the changes are because it’s such a
major major thing that affects all Americans and and frankly people around
the world right and I know you’ve uploaded a video that’s gone over these
and we’ve we’ve done the same because I think it’s important the the
implications are enormous we’re talking a hundreds of thousands millions of
people we’re talking about medications pharmaceutical companies everybody has
their has their say about you know is this a push towards farm and
pharmaceutical companies is this a push away from that lifestyle diet so let you
know if we just look at what the guidelines are there’s actually a lot of
interesting material there the first thing is that the last time these
guidelines really came out and were comprehensive was back in 2003 so this
is 14 years in the making there’s a lot of political issues with
this the National Heart Lung and Blood Institute basically handed over the
responsibility these guidelines back in 2013 to the American College of
Cardiology and the American Heart Association and so they’ve picked up
with it and now they’ve come up with these guidelines but what’s interesting
about these guidelines first two things number one is the classification both
the old and the new guidelines agree that a blood pressure of less than 120
systolic is okay it’s normal and both guidelines agree that any blood pressure
above 140 is abnormally high where they differ is that sweet spot between
systolic 120 and 139 and whereas before they were called pre hypertension they
wouldn’t get a diagnosis you know if somebody told you that you had pre
whatever your like well that means I don’t have it
right so now on the other hand instead of them not having it they’ve taken that
sweet spot of 120 to 139 and they’ve done a little bit of risk stratification
they’ve said that if you’re between 120 and 130 or 129 that that lower region
you’ve got something called elevated blood pressure do they just call it
elevated you get a diagnosis of hypertension you get the icd-10 code for
that whatever it’s gonna be and why is that well they’ve looked at
new research and though people are about two times higher the risk of getting
coronary disease and stroke so what they’re recommending for those people is
not necessarily pharmacological therapy but lifestyle then they take the second
strata between 131 39 and they say okay this is now stage 1 hypertension but not
everybody has to go on medication is about 30% of those people who have
either coronary disease or they’ve got a greater than 10% chance of developing
coronary disease in the next 10 years and they say those are the people that
we should start on pharmacotherapy whereas before they would just be pre
hypertension they wouldn’t be getting it so the question is is are there going to
be more people diagnosed with hypertension the answer is yes are there
gonna be more people on medications for hypertension I think the answer is gonna
be yes and so they’re getting more and more aggressive so the question is is
where did all this come from they’ve looked at all of these studies and the
big study to look at if you’re interested is a study called Sprint and
what they found and they excluded diabetics from this so that’s important
but what they found is that reducing blood pressure to below 120 as a below
as opposed to just 140 actually reduced ordinary artery disease cardiovascular
death and CHF so that’s basically the new guidelines in a nutshell and there’s
a lot of reverberation going on in the Nets and through the society so we’ll
see what happens yeah that’s the price to synced and accurate explanation I
think one one thing that I always think about is you know anytime you’re moving
the goalposts as it were the the ultimate goal posts you really care
about the thing we all care about is not like what label
and what drug even but are you preventing deaths which you alluded to
and already preventing bad outcomes and we’ll see you know in 5-10 years if
giving more meds now which is pretty much what everyone agrees is gonna
happen really does those things and when we hope it does we hope it prevents
deaths prevents you know real severe hypertension from developing because you
started earlier you were more aware of it and the analogy would be you know
something like colon cancer where if I know that you know I’ve got you know
some sort of familial polyp a lot of colon cancer my family I’m
gonna get early screening I’m gonna be more vigilant about it
so that’s your 120 to 129 range we’re not elevated heparin I’m gonna be
thinking about it more may be getting more frequent checks than I otherwise
would have because we know that that seems to be predictive of a bad outcome
down the road it makes sense and I understand why but I also understand
that the concern around you know these major major powerful groups getting
getting more money and getting more more patients using their medications and
things like that exactly I think what’s important is that they’re at least
they’re stating that they’re that what’s driving this is evidence-based and I
think the evidence is there the other interesting thing about this is the way
we monitor blood pressure and you know back in the 1980s 1990s how do we get
blood pressure medication readings we got it by going into a doctor’s office
and some healthcare professional measuring our blood pressure now what do
we have we have fitbit’s right we can know more about the human body
when we’re not in the doctor’s office than we ever dreamed up what they’re
noticing and what the issue is is that you know blood pressure is a result of
your environment if you’re under stress you’re gonna have a higher blood
pressure and so every any time anybody goes to the doctor’s office there could
be under a little bit more stress and so what the finding is is that these
ambulatory blood pressure monitoring and home blood pressure monitoring are
typically a little bit lower than what we’re seeing in the doctor’s office and
so if we’re gonna be using those to generate hypotheses it makes sense that
we’re probably gonna have to lower down that classification to meet those
numbers yeah exactly and that point is huge right like
right now we see a doctor maybe once a year and maybe twice a year that’s a
snapshot you know that’s literally like taking a Polaroid camera and just
snapping two quick shots you know that’s all you get and what you’re moving
towards is a movie where you just watch someone continuously and you get such a
rich understanding of kind of what their blood pressure is doing and blood
Sugar’s doing and all this kind of stuff and so we’re gonna see much more of this
correcting of guidelines as we get better and better data sets and saying
okay you know what a one-time check of 135 that actually means that probably
most of the time as you correctly pointed out you’re riding at 140 145 and
so as I see that and correlate that we’re gonna get more and more accurate
assessments of who really is at risk and who isn’t right and it’s almost
analogous to the hemoglobin a1c right which was a built an average of your
three months of blood sugar exactly and we don’t have that for hypertension yet
but you know you could easily imagine that we have a new measure that you know
as you said 50% of what you know you know in two years we’ll be doing this
this again you and I and we’ll talk about how how you know the guidelines
are out because we have better data sets and now we’ve now we call it the you
know hypertension a1c or you know whatever it is but like some long-term
measure of hypertension rather than just a snapshot the other thing that they
talked about that I was surprised at was this thing called white coat
hypertension I remember when I was quote growing up I remember studying mix app
if you remember mix app except was that thing for internal medicine and I
remember studying a mixed-up question and the thing you have to know for this
question was that white coat hypertension was a risk factor for
getting left ventricular hypertrophy right so now what are they noticing that
fits into the 50% that was wrong what they’re noticing is white coat
hypertension which again is you have a normal blood pressure at home and you
come into the doctor’s office it’s a little bit elevated well when you follow
these patients out their risk for for coronary events is the same as those who
are normal tensive so so in other words if we take that blood pressure reading
in the office we could be treating patients that don’t really need to be
treated I teach over at Loma Linda University
one of the things that we’ve been doing is every three or four months I have to
go in and teach third-year medical students about the pulmonary aspect of
medicine and we try to do that in three hours so imagine going in at one o’clock
in the afternoon and coming out at five and just me talking for four hours about
everything from the five mechanisms of hypoxemia to the reasons why someone
gets a pulmonary embolism now what we’ve done is we’ve put that whole lecture now
online and and now what I do when we go in is we usually we have like a little
Jeopardy session you know medical jeopardy so you do that for about an
hour and then after that we go up to the simulation lab and for the next hour we
talk about a case we simulate a case and I think that’s that’s kind of part and
parcel of what flipping the classroom is but Rishi tell me one of the biggest
barriers that I see at least on our side and you can tell me what you see on your
side is sometimes the students just don’t get down and and look at the
material before the class what’s the best way that you found to make sure and
make that make sure that that happens yeah that’s that’s the biggest issue and
a lot of faculty struggle with this as well at Stanford one thing that they’ve
done is they’ve started doing almost like on and actually some of the meetups
are in physical spaces that are not in the classroom so they’ll have a few
faculty members like five faculty sign up for a random Friday night to go to a
really nice bar or a really nice restaurant and they’ll invite students
to come to that place and just talk to faculty about whatever they want to talk
about and the idea is that you would only go there if you wanted to go or
they’d have a discussion topic like let’s talk about hypertension and the
idea was that you’d only go there if you’ve actually prepared for it you know
if I’m gonna go and and it’s somehow a social setting seems different I think
sometimes when you go to a physical place I collect Rahal because we’re
pre-programmed to think we’re gonna get spoon-fed like like you and I were right
that’s what you should kind of be used to but somehow just moving the physical
space or different space gets people in a different mindset like oh I’m going
almost like a book club if I’m gonna go to the book club
I’m gonna read the book I’m not just gonna go to the book club if I don’t
read the book I’m same idea like you would only go to these meetups with
faculty if you’ve actually done the pre-work and
it becomes really evident when you go to these places and you have done the
pre-work that you you aren’t able to participate as fully and so I think
that’s been one kind of small trick but it’s a psychological trick it’s just
literally moving the space to a different location and people start kind
of only going and only signing up to go if they’ve done the pre-work and it’s
kind of a neat thing because unless people show up frankly you know because
they people haven’t done the work don’t show up and that’s fine then they can go
you know stay home and do the pre work while the folks that do show up have a
rich discussion about it it’s about engagement and getting them engaged in
lifelong learning I know these are all catchphrases but I
really it does have actual meaning yeah and I mean as a med student you know a
lot of the value you get is not from your faculty or from your books it’s
from your peers right like the people that I really trust today are the people
that I studied with that I grew up with essentially my cohort and so if your
cohort isn’t enriching your experience that sucks and if you’re not enriching
theirs you know you’re you’re kind of the reason that it’s making it suck for
them so I think that that’s an important piece is that when you start med school
or nursing school or anything you have a responsibility to your peers to do your
work and that’s not just to yourself but it’s to your peers and if you can kind
of frame it that way then you’re not just letting yourself down when you
don’t prepare you’re letting everyone down now the problem is that so many
people get caught up you know in bad classrooms not understanding some basic
thing yeah that’s not the hard part you can cram that part the part that you
shouldn’t be cramming is the discussion in terms of how it applies to someone
you know and that’s what it should be like our videos are just like yours that
are short videos I want them to be short because I think that that’s the easy bit
you know it’s easy to just understand the new guidelines but what’s hard is
you know understanding how it applies to a person and saying okay here’s a 17
year old person comes in with blah blah blah what would you do that’s the part
you can’t cram away well doctor to say I really appreciate your taking the time
to meet with us and to talk with our our med cram subscribers and viewers out
there I think that we are together making it there
for its one video at a time absolutely thank you so much Roger I appreciate it

14 Replies to “Flipping the Medical Classroom & New Hypertension (HTN) Guidelines – MedCram Interviews Osmosis”

  1. I loved this type of discussion video for medicine. Where can I find more, particularly about new EBP research and guidelines?

  2. View two of Dr. Seheult's most popular courses at MedCram.com:
    𝙃𝙮𝙥𝙚𝙧𝙩𝙚𝙣𝙨𝙞𝙤𝙣 𝙀𝙭𝙥𝙡𝙖𝙞𝙣𝙚𝙙 𝘾𝙡𝙚𝙖𝙧𝙡𝙮 https://www.medcram.com/courses/hypertension-explained-clearly-2
    𝙀𝙆𝙂/𝙀𝘾𝙂 𝙄𝙣𝙩𝙚𝙧𝙥𝙧𝙚𝙩𝙖𝙩𝙞𝙤𝙣 𝙀𝙭𝙥𝙡𝙖𝙞𝙣𝙚𝙙 𝘾𝙡𝙚𝙖𝙧𝙡𝙮 https://www.medcram.com/courses/ekg-ecg-interpretation-explained-clearly

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