Classical Medicine and booklists.

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Not a week goes by when either a medical student or some other healthcare provider asks me what books they should read. It is actually easier to come up with a list for medical students, because they actually have the background knowledge they need, even if they don’t know how to use it, than it is for other healthcare providers.

Back in my younger days I was involved a lot with classical arts, band, choir, classical dance, and martial arts. One of the things that I learned and applies to all of them is the idea of “classical training.” The ballet mistress was often fond of saying “a classically trained dancer can do any type of dance, a dancer who is not is a one-trick pony.

This can be demonstrated by notable names like Paul Stanley (of Kiss fame) that play The Phantom of the Opera or the classical piano brothers, Alex and Eddie Van Halen…There are also several online articles critically reviewing the music scores from Rock musicians of the 1970s and 1980s comparing both the technical complexity of the instrumentation as well as the musical theory of the scores, which conveniently support my point that a classically trained musician is both more complex as well as skilled than other artists who essentially learned to play by ear or focused on one type of music.

I see this same parallel in medicine. From EMS to the most advanced of specialist doctors, there is an obvious difference in the capability of the provider based on whether they embraced a more classical style of learning compared to being focused on only passing the test or specializing in a given form of medicine.

To better explain this difference, let us look at what it means to be a “classically trained artist.” Whether it is music, dance, drama, or even a martial artist, training is scientific in nature. Music theory, kinesiology, and other basic mathematical and physiological principles are learned and applied. The early exercises are tedious and outright boring, and often do not outwardly resemble what is seen in the finished product. In fact, when you first learn music or dance, there is no music. There is counting. Explanations of how progressions work, chords, scales, combinations, etc. It requires discipline to not get extraordinarily bored and give up. Eventually, these basics turn into rudimentary performance, the kind your parents smile and hope they don’t have to go to. As you progress in skill, the underlying science and technique is not lost or forgotten. Much of it becomes second nature, reflexive, with detailed focus of it in practice, and no hint of it beneath a virtuoso performance. In fact most virtuosos are described as such from their mastery of the technical foundations and application of their respective arts.

Compare

I experienced this first hand throughout my medical career, starting in EMS and all the way through my MD and PhD. At all stages I had peers that focused on a less traditional way of learning. They had more free time, got better grades, could score the hell out of a standardized test, and can even create research papers that look incredible, but have absolutely no scientific basis to their clinical outcomes or conclusions. They are numbers on a page that demonstrate what they want to be true is. It is sort of like a musician that plays by ear. They are able to do it, but completely lack any level of underlying understanding. Consequently, the discoveries as well as guidelines that come from such style are often disproven or found to be ineffective or harmful over time. The actual practice becomes an exercise in dogma and there are no shortages of fads and ever changing consensuses constantly being updated.

How did it become so? Well having had the chance to be educated in both the US and Europe, I have come to recognize a distinct difference in how education is done. US education is largely rote memorization, discordant facts to be memorized and identified on standardized examination. The technique is simply “when I see X my response is Y”. Y = X and therefore X = Y. By memorizing the material that way, the equation can be made longer, if X = Y then Z. As such Z = both X and Y, which becomes a circular form of logic which gives the illusion of complex understanding. Not because the material is complex, but because there are simply more variables which equate to each other.

That is in contra to the more European style of education, which is largely focused on more basic theory which does not explicitly state the equations but rather covers information which leads to “discovery” of patterns, similarities, and equalities. There is far more of what educators call “scaffolding” where what is learned at one level repeats and carries on into others. US educational facilities attempt to emulate this to some degree, but because classes are both seen and sold (in the form of tuition) as individual entities, much of the continuity is lost. That is to say nothing of the discovery or ability to logically deduce the next step or pattern. The US is not alone in this practice, it can also be seen in the UK and Canada. It is the standardized test that becomes the focus. Memorizing what might be on it to identify. I would point out that none of the countries that have achieved high effectiveness of education use standardized testing. But it is a 4 billion dollar a year industry, and drives everything from the making of the exams themselves to books and “study materials” sold in order to pass such exams. I think you can easily see where this essentially nullifies any type of scaffolding or understanding passed association. If you don’t believe or see it, just go to the doctor when you are sick after you have googled and printed out research on any given disease you may be afflicted with and watch their reaction. Question their insights on it. You will find they can regurgitate a lot of associations, but for the most part lack any in-depth understanding of it and will offer you “routine” treatments as those are associated in classic X = Y therefore Z type of understanding. If you press the inquisition and ask “why” you will not get a lecture worthy of any university professor, what you will get is a circular form of association, as I described above.

This style of learning is carried on even after school, residency is taught the exact same way. In fact, many doctors in residency hear “you can forget the stuff you learned in school, it doesn’t matter” from their preceptors. You hear the same thing in the MD portion of medical school when discussing undergraduate science education. “Forget about it, it doesn’t apply.” If it doesn’t apply? Why do you have to learn it? Wouldn’t it just be quicker, easier, and cheaper to essentially tell any student to become a doctor to forget formal or in-depth education and simply emulate a doctor in the specialty you want to practice for a few years? That is essentially what is happening, the training of role specific behaviors, completely ignoring all previous education. That knowledge isn’t even valued by healthcare providers. We see all the time how “mid-level” providers have an abridged medical education, perform the same behaviors and roles, and even claim “we are just as good as doctors” or even contemptuously “young doctors don’t know anything!”. What this effectively demonstrates is not a learned position, but one more like that of a factory worker, where the person with knowledge, but not practical skill mastery is seen as lesser, or of no value.

So when I am asked, “what books should I read?” I respond to the question with a question. “Do you want to be great or do you want to be able to perform quickly?” If you want to be great, you can forget about Tintinalli’s Emergency Medicine Manual (or any other physician level text), because while it will expertly teach you what to do, you will have absolutely no idea why. That “why” will come into play time and time again, as circumstances change, treatments fail, patients fall between the cracks where multiple specialties each do a little, but nobody takes care of the whole. It will determine what treatments and procedures are stocked, performed, and/or paid for. It will not only determine when to do something, but when not to. At which point it will all become essentially the provider feeling lost, fearful, and prudence will dictate taking no action, which ultimately brings harm to the patient. All conveniently brought to you by “I forgot all of that stuff I learned prior to now, so my world is a big mystery on all sides.”

If you simply want to perform, to have the illusion of knowledge and some practical X=Y therefore Z sort of stuff, then by all means, pick up “So and So’s guide to emergency medicine, anesthesia, internal medicine”, or whatever form of medicine makes you happy. Memorize the treatments as they were 5 years ago or watch your podcast from the “experts” of what is in fashion today. Just like somebody that picks up an instrument and tries to play it by ear or learns their favorite dance at a club, you will be able to put on a good show, maybe even one pays money for…But you will never be great, you will never be a virtuoso, you will never be able to adapt and improvise.

If you want to be at that level one day, you need to start with the basic exercises of medicine…Biology, physics, chemistry, biochemistry, molecular biology and all those things that those who are not masters claim are not important or can be forgotten. At first it will not look or feel like you are learning medicine. It will be like learning music theory or the basic movements of ballet. No music, no flash, counting…repetitively. Until you can integrate it without having to stop and think “what do I know about chemistry.” From there you can move on to your rudimentary performance (you know, the recital your parents hope they don’t have to go to, but smile and clap for you anyway) and start picking up books on “medical science” like anatomy, physiology, immunology, etc. Then as your skill as well as knowledge progresses, you move onto more specialized knowledge, but never forgetting to spend time practicing and perfecting your basics. When you have spent the years becoming competent, then you can take the step to not only being able at your craft, but contributing something new to it, by being able to reflect and analyze every aspect of your art and of each of your performances.

Medicine is not an art and a science. That is cliché, medicine is art. A performance. Just like a classical musician or dancer, it is the mastery of the underlying science that permits that performance; the greater the mastery, the greater the performance. The path of the virtuoso…

It is long, at first thankless, and requires tremendous discipline. But if greatness is your goal, there are no shortcuts. No “easy” ways. It is the difference between playing on the stage and commanding it. The difference between community theatre and the Bolshoi. The difference between being among your peers and standing out from them.

The only thing more difficult than accepting the hard way is becoming skilled at the easy way, hitting your peak, and in order to get better, having to go back and start again from the beginning.

The choice is yours.

In the middle of nowhere…

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Well…today I am reflecting. This may come as an unusual twist to my recent writings consisting of acute stressors in life that usually just piss me off…

So today I am considering life from the victory conditions of one of my favorite video games of all time. Generally I like video games, particularly complicated ones. The one I am thinking about today is easily one of my favorites because it is complicated enough to focus the entirety of my thought processes. This indirectly brings peace to me because when I have to focus the entirety of my mental faculties on not getting my ass kicked by the computer, I don’t have any capability to turn to more destructive thoughts.

This particular game, based on WWII, was largely developed by enthusiasts over a decade. While the functions are relatively easy but numerous, the volume of information which must be learned to effectively play the game takes years. After each battle in the campaign, you are scored as:

Decisive victory: you have achieved all predetermined victory objectives and inflicted at least 10x the destruction on the enemy as it inflicted on you.

Marginal victory: you have completed all or a majority of predetermined victory objectives and inflicted 5x the destruction on the enemy as you suffered.

Draw: you have achieved a minority of victory objectives and or caused casualties equal to <4x those inflicted on you.

Marginal defeat: you achieved some of the victory objectives, but with losses equal or greater to those you inflicted.

Decisive defeat: you either achieved none of the victory objectives, and/or lost >3x the amount of casualties inflicted on the enemy.

My life is a marginal defeat. I have my moments, and those moments are usually really good, but they are few, and the losses suffered while not always catastrophic, seem to outnumber the gains.

So this begs the question, if I am losing, why don’t I change something? As if I don’t constantly try to change something… It doesn’t take me too long to figure out if I am winning or losing at something, even when I am perhaps holding on to a vain effort longer than I should.

But I seem to exist in this strange void or limbo. I am simultaneously part of things but also not a part of them. Here are some examples.

Nationality. So far I am still an American, I know I should probably ditch that citizenship, all objective measures determines the drawbacks exceed the benefits, but I can’t seem to bring myself to it. Perhaps sentiment, but perhaps just so I have some form of group identity. After all, I am a Polish National too. (US law allows a person to have up to 3 citizenships, and I do think it would be cool to get a 3rd just to be one of the rare people who have 3. I have actually met a couple of those people, and that is a trophy not many can claim) But if you ask any Polish person, they will tell you that I am not Polish. Not because of my language skills, but because of the way I think and see the world and life. It is a world of possibilities, of opportunities, of dreams and goals, not some mindless grind of be born, go to school, get a monotonous job, get married, have kids, retire, die. Another characteristic feature that distinguishes me from my Polish counterparts is that like most Americans, I believe I can win. At whatever I am doing. Not just do it to some minimal level of competence and/or getting a trophy for coming in 9th. (They give out trophies for 9th place?) But be number 1. The best. The top. The undisputed heavy-weight champion of the world. Now while there are Polish champions, in the greater Polish society, they are generally outcasts, so, I win the outcast award too, simply for trying to be the best.

Conversely, despite my having to go through the headache of filing my yearly tax returns as Americans are the only people left in the world that get taxed as expats, filing special treasury forms for my bank account and life insurance to make sure I am not some hidden millionaire evading my share of US taxes, which is outright laughable with my income. If you ask many Americans, I am definitively not an American. I can’t really figure out why, the reason I am most often told is because “you do not live in America,” but by that standard it would be fair to say any American not living in America is not really American, and that would strip citizenship from some unsuspecting people, like military service members.

So on paper, I belong to both the USA and Poland, but in the practical sense…I belong to neither. The middle of nowhere.

My career, which went from something really good to an utter disaster after moving to Europe (it is not just Poland, Poland has done a lot for me, and I tried living in the UK, that was a disaster not worth repeating) has convinced me that it is Europe in general that is bad for my career. Especially since most places, my previous titles and skill set doesn’t exist or has no perceived value.

Officially I am a doctor and a scientist. What kind? I like to think a good one, but that is one of those “you don’t fit in” issues too…

When I went to medical school it was with the goal of becoming a critical care surgeon. It never occurred to me that medical specialties and practice were different outside of the US. I mean when you hear that America is always the best, you just assume everyone is trying to be like them…Yea, I was naïve and not well-traveled once too, I must apologize for not being born omniscient. (Don’t tell my daughter, she thinks I know it all right now, so I figure I have 3 or 4 years left before she decides I don’t know anything.) It didn’t occur to me to research that it might be different. So not knowing what I didn’t know I just showed up. Forget culture shock, it was everything I knew to be true in life wasn’t shock. Even buying food at a restaurant was simply unfamiliar. I had never paid for food by the weight before, nor had to order each piece of the meal separately to make it look like the picture on the menu…

But as medical school drew to a close, I discovered that returning to the US was not a realistic option. I was now a “foreign medical grad” and as such no matter what I did would rate somewhere on the resident desirability scale between some guy off the street and everyone else rejected this position. It was potentially destructive for me, my family, and any hope of finding a job above poverty wages. My parents are gone, and with the exception of some really good friends, there is nothing else to go back to. But this section is about career, so I simply figured…well then I will just invent it here…

That is turning out to be nothing short of a disaster. In addition to struggling with languages, I am in a culture where such lofty aspirations are actively fought against by all of society. In addition to being outcast for trying to break the 1000 year old status quo, for the benefit of people here! I find myself beset by problems like people not wanting to help me in my endeavors at all. People who take active measures against my efforts for their political gain, and of course…not belonging to any group but being between two of them…the middle of nowhere…

The quick quick summary is that throughout Europe, there are surgeons and there are anesthesiologists. (The latter is also the domain of both emergency as well as intensive care in all but the UK). So in order to make the critical care surgeon specialty work, the path of least resistance would be to get specialty in both. Probably for the only time in my life, I tried to take the path of least resistance, but it doesn’t seem to be that way to me.

When I am asked why I would do such a thing, I summon up all of my passion for helping people in desperate need and give my very best altruism as an answer. It has never been met with “really that is awesome” or even “cool”. Usually it is derision. “Why bother”, “you’ll never make money doing that”, “it will take forever”, and my all-time favorite…”Who do you think you are?”

So when I go to work in surgery, the surgeons without exception are quick to point out that I think like an anesthesiologist. When I work in anesthesia I am told I am too much like a surgeon. I once again seem to be both, but neither. The middle of nowhere… After the last two years I really self-identify more as a surgeon. I haven’t actually finished specialty training yet, trying to do 2 essentially makes me the world’s longest doctor in training, but from the point of view of mindset, surgeons are all about doing. Identify something needs done and do it. Granted there are limits to this for most surgeons, and that limit revolves specifically around operating on patients and very little before or after that act, but my experience with anesthesia is they like to set up systems requiring minimal intervention and are extraordinarily routine driven. That just doesn’t mesh well with my idea of individualized care; especially in environments like the OR or ICU where doctor to patient ratios are so conducive to it. I also don’t like to call for help for simple skills like chest tubes…

Besides, when I was in the UK, the A&E docs always referred to me as a surgeon, so at least 1 group made me feel like I was part of another instead of saying “well, he is like us, but not.” Yes, I know they were only saying that because I worked in a surgical service and they didn’t want to claim me as their own…but…marginal defeat still means some level of objective was achieved…

So what kind of doctor am I? I am in the middle of nowhere…

Now because not having great employment opportunity as at once being part of different things but not all of one doesn’t pay well, I supplement my income by teaching. I also like to do research to change what I see as substandard practice…

Many of my colleagues think that most PhDs are either good researchers or good teachers…and 5 pages in, let me just sum it up…I like to be good at both, and both groups identify me as “not theirs” and I find myself in the middle of nowhere again…This is a recurrent theme for me…

I recently was told by a friend on Facebook there is a superhero named “Dr. Strange” who did his MD and PhD simultaneously…That made me feel like a superhero, because I did exactly that. Looking back it was hard, and I suffered, but for the only time I can remember, I was learning at a rate that actually required my maximum effort and focus…Now I have a lot of time to waste. I would like nothing more to be involved and learning at that rate again. It was challenging. Exciting. Full of discovery. It also came with many compliments about being smart for the first time in my life.

But I haven’t had anyone call me and ask to be on their superhero team…Sort of makes that a hollow victory and lessens the super-ness of it…If anyone thinks you are a hero for being smart, let me set that right to rest too… I have been ostracized, even tortured my entire life for being smart. Nobody likes smart people and I have no idea why? Fear? Envy? I could theorize all day…I even had a girlfriend dump me once because she said it wouldn’t work out because she likes when everyone tells her how great she is, and it didn’t happen too often when she was standing next to me, so I was taking all of the attention she wanted.

What is it like to be smart? Well…I was once dating a different girl who asked me “do you dream in pictures or words?” I thought this was a silly question…both of course…like everyone else…that is when she told me that was not like everyone else. She then went on this speech about lucid dreaming, and how awesome that would be… I asked her quizzically, “you cannot do that?” All of my dreams are that way, ever since I can remember. It’s better than a movie, stop, rewind, rewrite the script, different camera angel, zoom in, zoom out. That is how it always worked for me. It never occurred to me it wasn’t like that for everyone.

I take sleeping on a problem to another level entirely…Consciously, while I sleep… my mind works constantly. It never stops 24/7/365. Just like many other things on this list, it never once occurred to me everyone was not like this until somebody told me.

Patterns. I can quickly spot patterns in everything. Even when others tell me there are no patterns at all. While not perfect, it makes my ability to predict things very accurate a high percentage of the time. It permits me to anticipate and prepare for problems before they happen, in most cases, or avoid them entirely. My wife hates it when I blurt out the next line in a movie that neither of us have seen before or figure out the ending ½ through the movie. (90s movies are the exception because for some reason they thought it is entertaining to essentially change the whole movie part way through). I am also never invited to escape rooms or murder mystery dinners… This happens passively, no effort required.

Complex thought processes. When I look at a conundrum or problem, I don’t do it with compartmentalized information. There is no such thing as simply “what I know about medicine” or “what I know about human behavior.” When a problem arises I identify every piece of information that I have (information I have is the limiting factor, and I want to be first in line if they ever invent the brain plug like in the matrix to learn things) as being relevant to the problem or discussion at hand, as well as identifying how, and what impact it has. Plus it is fast…This also has the added benefit of allowing me to imagine in real time what somebody is telling me as they say it. It helps a lot in pattern identification and breaking down lies, untruths, and cons.

Form without substance…Dogma and church-like rituals that don’t stand up to even basic scrutiny cause a hard stop in my thought processes, like a computer dividing by zero.  This then has to be reconciled and it usually takes me a minute or two to do it. That is when I am not just looking at people like “what the fuck were you thinking?”

“Ninja like reflexes” is how my reactions are often described. From practicing martial arts, catching dropped surgical tools, or dodging stuff people teasing or hazing me throw at me. So fast is the recognition and process it looks like slow motion to me most of the time. It comes with the added bonus of being able to process the geometry of throwing it back too, and in my mind’s eye, I can even imagine the equation angles.  As it happens. During one part of my fire career i was given the nickname “slide rule” for essentially taking the arc out of throwing a basketball though its hoop. It seemed totally unnecessary to use an arc.

Like a sponge…As I mentioned before, the only time in my life I was pushed to my maximum ability to absorb (and consequently integrate) information was while simultaneously studying for an MD and PhD. Short of that level of intensity, learning is effortless, and if experience is a wise teacher and a fool can learn from no other, I am no fool, because when you tell me your experience I can internalize it to the point I can smell the smells, taste the tastes, hear the noises, and tell you how you felt.

Calm to the point of appearing apathetic. Since most of the time thoughts go through my head faster than most actions, I don’t have to act as quickly as I think. Coupled with anticipation and pattern recognition, I can position for success in moments to come, rather than racing to catch up. Actually when I am racing to catch up is when I make the most mistakes at things. Second is when I am prevented from positioning myself for success and having to wait to react.

If you are thinking just now, “wow” this is like a super power… It’s not, it is a terrible curse that alienates people from you, causes people not to believe or trust you, makes them jealous, fearful, and constantly questioning how it is even possible. Which is a crazy question anyway, because it is as natural as anything you do. I have read everything from psychology to neuroscience, psychiatry, every article on the benefits of being left-handed…I have no idea how it is possible, it’s just natural, the way it has always been and it pisses teachers off to no end too. I try to be humble about it, I try to suggest rather than pontificate. But I admit, I sometimes quickly run out of patience for people who think I am not capable of understanding a single topic I have not been involved in for 20 years. I am also merciless when it comes to insulting my intellect, because I have suffered dearly because of it my entire life. When I am standing there telling somebody an answer to a conundrum while they totally ignore me and go on making mistakes trying to figure it out, it doesn’t make me think too highly of them either,because it seems to me, a preventable mistake. An obvious one at that.

When I was young, my dad, who was super smart (he worked in a factory most of his life, wasn’t even a foreman, and his hobby was subscribing to an astrophysics publication and working out the published data equations by hand while he ate dinner), but not formally educated because of lack of money and social status told me that a smart person only ever has 2 choices in life. They can help people or take advantage of them. I chose to help. It doesn’t make you rich. It doesn’t make you popular. Almost nobody ever wants you around until there is a problem and you can expect to be ditched right after it is solved. But for the disaster that is my life…the victory objective I achieved in my marginal defeat was not purposefully or maliciously taking advantage of anyone. Even when my council has been wrong, I have always believed to my core I was trying to help for the benefit of somebody else.
In closing…It’s better to be lucky than smart, but being stupid is bliss…Stupid people are never alone, there is always a big group of them ready to welcome other stupid people in.

well…7 pages…enough of my mawkishness. I need to go chase down another victory objective to make sure I am only being marginally defeated by life. What else can be done..? As another great mentor once said “if you are not winning then you are..?”