Classical Medicine and booklists.

Standard

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.

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