Introspection on medical education

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Not a day goes by I am not asked questions on how or if it is right for a person to be a doctor or some other healthcare provider. Many times I am asked on the internet my recommendation for books or study materials in just about every field I have been involved in. Once a semester I make my recommendations of books my students should have, my part-time job is teaching pathophysiology for a medical university. On many days, my clinical colleagues either marvel at or fear my ability to explain how insect life cycles are useful in human patient populations or how molecular and biochemical knowledge can be put to real time use treating patients in a clinical setting. It always seemed logical to me that the reason we study things like basic biology or physics is so we can use that information to make better decisions for patients. After all, if it made no difference why bother studying it or paying people like me to teach it in the first place?

Now in all fairness, there is an opposing view to this shared by some of my colleagues and critics; their position is that education should be more linear and practical. Back in the early days of computers we called this type of algorithm if:then. It has been my observation that specialty training, or medical residency, revolves around this type of learning. It also has not escaped my attention that some countries, like the UK, actually purposefully develop their education systems focusing on such style. I will not argue the merits of the two systems, but I will concede there are benefits and drawbacks to both.

Today, I hope to share some insight on how I go about learning, teaching, and the implications of the type of medical education I advocate for and profess.

It is said that everything large is made up of small parts. This is certainly true in both physical and natural science. It is also true in clinical skill. Compare the time spent doing “small” things for patients compared to “large things” like procedures or surgeries. It has been my experience that < 1/3 of my total day is ever spent on the “large” or major parts of patient care. Surgery, diagnostics, etc are a very small portion of my day. The largest portion of my day is by far talking to people. Mostly I am explaining or “teaching” patients; listening to their concerns, attempting to find desirable solutions, etc. Clearly that “small stuff” makes a difference.

Because I started my professional education from the fire and EMS perspective, and not that of a traditional doctor, I have come to discover that my education is exactly backwards. With very little information about basic or even clinical science, I was put in the position where I would be taking care of the most sick and unstable patients. As my career progressed, I learned more and more about taking care of stable and even routine patients. Easily over my career, the patient population I have spent the most time caring for are emergencies.

This is in contrast to the traditional doctor, who spends a lot of time in school learning about things that are not easily or apparent to clinical practice; basic Biology, Chemistry, Physics, and all of that early or “premed” stuff that has more to do with abstract concepts than what procedure or medication you give to a given patient. They follow this up with internship and “specialty training” which escalates them over years from seeing the most mundane patients to eventually some emergencies.Traditional doctors spend most of their career caring for patients who are stable, in early disease processes, or otherwise not critically or acutely ill.

This diametrically opposed experience has put me in a position where I don’t really have many peers in medicine. My experience with critical patients far exceeds many of the most senior doctors. My knowledge and interest in patients I would call “not sick” and the routine of dealing with them is on the other hand, not always equal that of my colleagues.

Several years ago I was asked by a respected colleague which of the two methods I thought were better. As I was trying to cultivate a friendship, and not wanted to just say “the way I did it is way better!” and make him feel like he was lesser, I very, and uncharacteristically diplomatically, told him there were equal merits to both methods. However, at the time, I think I was considerably more generous to the traditional method than it deserved. In retrospect, I cannot find too many nice things to say about the traditional method.

This of course carries over into my teaching. In my lectures, I make a concerted effort to explain how the basic sciences, the little things, are important to the big things and vice versa. This means when I am talking about a clinical disease, such as peripheral artery disease, I explain the gross clinical findings, then the subclinical findings that have to be teased out with examinations, the organism, organ, tissue, cell, molecular, and finally biochemical processes. Then I repeat it in reverse. It makes it seem real. Demonstrates how the small is practical. Shows how understanding it all changes what can or should be done for patients. It also helps to teach students how to critically look at medical studies. They see and adopt my idea that if a clinical study tells you what to do, but not why or how, it is suspect at best, and not very valuable for much else than convincing administrators to pay for something.

Today, I was asked by an aspiring EMT student, what is a good book to read before class starts. Undoubtedly he was expecting some EMS textbook or study guide, but my best advice was a biology text. Without the small, there can never be big. Most biology texts actually start out with a fair amount on physical science. Because the building blocks of natural science are physical. Physical scientific concepts can and do exist without natural science in every place in the universe life is not found. Contrarily, all natural science cannot exist without physical science.

Basic concepts like cellular machinery are required to understand not only how cells, tissues, organs, and organisms work, but also how they break down. This in turn translates into physical findings, diagnostic findings, what is directly appreciable, what is indirectly measurable or appreciable, and most importantly, what can be done about it. To understand biology, one must also understand chemistry and physics. Then they can move on to molecular biology and biochemistry. Followed by anatomy, physiology, pathophysiology, pharmacology, etc.

However, without showing or explaining how these concepts relate to the big picture or patient care, the value of this information is lost. In my not always humble opinion, that is the responsibility of the teacher. A teacher who does not understand this is completely useless and certainly overpaid.

I think early clinical exposure and decision making is the key to success in medical education. Nobody really needs a doctor or paramedic to expertly run them through a bureaucracy. They need expert secretaries for that. They need people who can use knowledge of science to somehow change their lives. In fact, I tell people the whole point of a doctor is to use scientific knowledge to positively alter people’s lives. That doesn’t always mean surgery or medications, but it does always mean medicine. Recognize that early medicine men or shamans had very few surgical or pharmacological interventions. Even fewer diagnostic tests. But they did command the same position in society that modern practitioners do.

One of the early lessons I like to teach students is how to apply basic chemical concepts to medicine. For example, Avogadro did not have a mass spectrometer to measure chemical substances, so he created a standard way to practically measure various atoms and molecules. This has come to be called a Mole. It is fashionable as of late to adopt this measure for diagnostic testing, measure in mmol/liter, and all of its metric derivatives. But you also have measurable moles of medications, which measurable cross various body compartment. You have a given amount of moles of heart cells, brain cells, etc. If you are trying to imagine how much sugar is in blood in moles, why would you not attempt to imagine or visualize how that interacts with other molecules in a given volume? Sure you can memorize abstract values or normal and abnormal, but then how do you use it? How do you work with it? It can seem as simple as if:then when you are only dealing with one variable. But reality is humans are not one variable. They are an assortment of biochemical reactions in a watery medium. That sugar has implications for more than just blood. It has implications for the liver, metabolism, anatomy, endocrinology, neural function, which in turn effects respiratory and renal function. Altered mental Status, body habitus, Kausmal’s respirations, metabolic acidosis, diuresis, all of this is connected to that sugar. How are you possibly going to memorize the totality of clinical diseases and their presentations without understanding what causes them to be? How are you going to create a differential diagnosis if you do not understand the interplay and make reasonable judgements on what is a primary cause vs. a symptom? How are you possibly going to treat it appropriately? Thousands of diseases, hundreds of similar presentations, uncountable treatments. It is much easier to understand how and why than to memorize all of that. Rather to think you can memorize all of that, because nobody can.

It is often said in jest, but there is quite a bit of wisdom in it. Patients are not just hearts or kidneys. While a doctor can “specialize” in a given organ or pathology, without understanding how various pathologies come about, what will she do for a patient with multiple pathologies? How will she even figure out which “specialist” or when a “specialist” is needed? It is simply not practical nor reasonable for doctors not to be able to take care of basic patient needs and require outside consults all the time. A patient who has a cold on an ortho ward should not require the consult of microbiology and internal medicine. A patient in a surgical ward post operatively should not require an anesthesiologist to manage their pain appropriately. For certain if the infection or pain is refractory that is when a specialist should be engaged. But without even knowing or trying basic interventions, the job of caring for a patient is incomplete. In my characteristic non-diplomatic way, I would say half-assed.

So 4 pages in and nobody paying for my insights here…Whether you are an aspiring EMT, Nurse, Paramedic, Doctor, or healthcare professional I didn’t type here, learn what is small, learn what is big. Understand how it applies. Yes, learning the life-cycle of insects is directly applicable to humans. Whether or not you call something a larva or a fetus, it is in the same stage of life, which functions with specific physiology until it changes to the next stage which has similar physiology between insects and humans. The diseases and presentations of all pathologies are found in various or all stages, some in specific stages. The epidemiology and treatments also depend on these specific stages. As does the reasonable palliation of various diseases opposed to curative strategies.

Medicine is not easy no matter what your title or scope. But if you understand it, you will never fail to be great at what you do. Like a classical artist, nobody starts as a virtuoso. It starts with the most boring repetitive, seemingly pointless exercises. Without those early stages, greatness can never be achieved. If somebody tells you there is a shortcut or an easy way, they are either a fool or a liar. If you just want to do the minimum you have to and get paid instead of being great, I challenge you. When you introduce yourself to your next patient, look them in the eye and say “hi” my name is (title) (name). I didn’t get into my profession to help you, I did it to help myself, and I don’t want or care enough to put in the effort to be the best provider I can for you. I want to do the absolute minimum for the maximum pay.” If you can do that, and the patient is ok with it, I will never judge you poorly again. If not… Maybe you ought to try my way?

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