October 20, 2009

Medical training

I was once told that in order to truly offer insightful criticism to a process or institution, one had to be a part of it. To some extent, that's true. Since reform of the way doctors do business is so much on everyone's tongues lately, I thought that whenever I saw something of note, I'd comment on it. So one complaint I've heard is how hard it is to find good doctors. Personally, my family had this problem. When my dad went through some heart difficulties, I figure the rate of finding good doctors was about 50%. It was true of family practice and it was true of highly specialized electrophysiologists. To make it worse, those in the lower 50% weren't just not good. Some of them were downright dangerous. So here's my question. Any population has a bell curve and down at the bottom are the idiots. Do doctors have a disproportionate (less or more) number of idiots in the field or is just that the idiots are just so much more obvious? One might expect that a field that supposedly weeds out the lesser talented would have less idiots. I'm not convinced of that. I don't think that the process necessarily cultivates idiots, but I do think that it may cultivate the wrong sort of talent. Doctors aren't doctors because they're good at being doctors. They are doctors because they are good at taking tests. Obviously, I've just over generalized about a huge profession of which I hope to belong to someday. But my point is that test taking weighs HEAVILY on deciding whom can become a doctor, not on skills. There are so many standardized tests along the way as to be ridiculous. But let me not go off on generalities. Here's a specific example that might help illuminate the point. In histology, three times during the semester we undergo what is dubbed "Team Based Learning". It's essentially a very basic patient history with a biopsy slide of the relevant organ. The goal is to get people thinking very basically about diagnoses. Well, today it was liver and the hypothetical patient was an alcoholic. Pretty clear case of liver disease due to over indulgence in spirits. One look at the slide and the liver had a TON of inflammation, ie lymphocytes. Everybody in our group said the same thing after looking at the slide. One of the questions inquired as to which cell type was increased. Pretty easy to say lymphocytes. Apparently, one group didn't put the correct answer because the peripheral white blood cell counts were not increased. No biggie. Everybody gets things wrong. But the student proceeded to argue their case to the professor that "how were they supposed to know that peripheral counts didn't correlate with tissue activity?" And in my head, I am thinking, this kid is falling into the fallacy that doctors more and more are falling into and that is treating numbers rather than disease. With the advent of all these new fangled technologies, there is a temptation to rely too heavily on these high tech diagnostics. They are powerful tools, to be sure, but they are replacing the art of thinking critically. Had this student taken one look at the liver, it wouldn't have mattered what the peripheral blood looked like. Think critically and ask, should the liver be full of inflammation under normal circumstances? Which gets to my original point. The class is selected based on their ability to take tests (myself included). This student was clearly arguing from the standpoint of test taking. At no point where they actually interested in learning why alcoholism leads to inflammation. They just wanted the points. At the end of the course, I'm going to go talk to the professor and give my two cents. I think he should expand on these situations and get these kids to start thinking rather than regurgitating. I'm starting to see why some med schools have forgone grades for a pass/fail paradigm. Stop worrying about points and start thinking about how you'll treat patients.

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