We need to foster comfort with uncertainty and discourage rigidity in medical education. I teach in the anatomy lab, and I'm always very surprised by how negatively some students will react when told to change course from their dissection guides (because of a surgery in a donor or other variables), even when it comes from the faculty responsible for writing said guide.
I would add (and my work is mostly untangling "why is X not working, I followed the guidelines" questions, when the usual is the obvious, the diagnosis is wrong) - I would add, the usual REASON the diagnosis is wrong is following consensus pathways without the addition of clinical reasoning.
I usually say, "AI 'thinks' like a medical student" (yes, I know it's not actually thinking). What I mean by this is it analyzes diagnosis as if it is a fact-stacking problem and not as an insight-driven engagement USING facts but clarified by the senses and by pattern recognition. Medical students have facts but no patterns, and their senses are not yet trained.
Given the limitation that by the time I am seeing a complex problem AI may have already failed at diagnosis - seeing errors is not uncommon.
In my first week of medical school, in 1972 (when they bring in old guys to tell you what the shot is, before you get down to work), an experienced clinician told us, "You will all want to practice in accord with the literature" (that's what they called EBM back in the day). He went on to say, "There are two problems with that. First - Half of what is in the literature is wrong. Second - we don't know which half".
There is nothing new under the sun, except that the "half is wrong" fraction may be growing.
A thoughtful, clearly articulated and convincing argument for the application of thought to clinical problems.
This is particularly true for residents and subspecialty fellows (not medical students) who focus on learning how their local institution manages particular problems, and, when in doubt, fall back on “authoritative” guidelines that are, at best, compromise documents.
Guidelines are often the refuge of the rushed physician in the trenches, to their patients’ detriment.
Similar issues in nursing school: My students don't tolerate ambiguity. "The doctor ordered it, so it must be okay. The hospital guidelines can't be wrong, etc." My students do not appreciate my questioning established protocols. The underlying issue is how to help students and practitioners become comfortable questioning all medications, interventions, etc. I constantly say to my nursing students, "Is this really doing what we think it is doing, and is there a better way?"
I thank Sensible Medicine for teaching me to critically appraise guidelines: they examined the recent Lipid Lowering Guidelines and exposed the lack of concrete research results underlying even the Class I recommendations. These guidelines state as fact actions that aren’t supported by RCT results. Yet, as this writer states, many take the guidelines at face value without critical appraisal. And medico-legal pressures cause blind adherence to the guidelines. What a mess. And I really worry about the LLM/AI compilations of studies that will also pick out the ones that support big pharma or device makers. What is one to do?
Well said. I think one aspect of the problem is the way we select medical students. People who do well in undergrad science courses and have high MCAT scores are people who are good at memorizing things. That's a very different skill--indeed, a very different mindset--from conducting research, analyzing conflicting information, wrestling with ambiguity.
Great article!
We need to foster comfort with uncertainty and discourage rigidity in medical education. I teach in the anatomy lab, and I'm always very surprised by how negatively some students will react when told to change course from their dissection guides (because of a surgery in a donor or other variables), even when it comes from the faculty responsible for writing said guide.
I would add (and my work is mostly untangling "why is X not working, I followed the guidelines" questions, when the usual is the obvious, the diagnosis is wrong) - I would add, the usual REASON the diagnosis is wrong is following consensus pathways without the addition of clinical reasoning.
I usually say, "AI 'thinks' like a medical student" (yes, I know it's not actually thinking). What I mean by this is it analyzes diagnosis as if it is a fact-stacking problem and not as an insight-driven engagement USING facts but clarified by the senses and by pattern recognition. Medical students have facts but no patterns, and their senses are not yet trained.
Given the limitation that by the time I am seeing a complex problem AI may have already failed at diagnosis - seeing errors is not uncommon.
In my first week of medical school, in 1972 (when they bring in old guys to tell you what the shot is, before you get down to work), an experienced clinician told us, "You will all want to practice in accord with the literature" (that's what they called EBM back in the day). He went on to say, "There are two problems with that. First - Half of what is in the literature is wrong. Second - we don't know which half".
There is nothing new under the sun, except that the "half is wrong" fraction may be growing.
A thoughtful, clearly articulated and convincing argument for the application of thought to clinical problems.
This is particularly true for residents and subspecialty fellows (not medical students) who focus on learning how their local institution manages particular problems, and, when in doubt, fall back on “authoritative” guidelines that are, at best, compromise documents.
Guidelines are often the refuge of the rushed physician in the trenches, to their patients’ detriment.
Similar issues in nursing school: My students don't tolerate ambiguity. "The doctor ordered it, so it must be okay. The hospital guidelines can't be wrong, etc." My students do not appreciate my questioning established protocols. The underlying issue is how to help students and practitioners become comfortable questioning all medications, interventions, etc. I constantly say to my nursing students, "Is this really doing what we think it is doing, and is there a better way?"
This excellent article shows a level of understanding that is unusual for one so early in their medical experience.
I thank Sensible Medicine for teaching me to critically appraise guidelines: they examined the recent Lipid Lowering Guidelines and exposed the lack of concrete research results underlying even the Class I recommendations. These guidelines state as fact actions that aren’t supported by RCT results. Yet, as this writer states, many take the guidelines at face value without critical appraisal. And medico-legal pressures cause blind adherence to the guidelines. What a mess. And I really worry about the LLM/AI compilations of studies that will also pick out the ones that support big pharma or device makers. What is one to do?
Well said. I think one aspect of the problem is the way we select medical students. People who do well in undergrad science courses and have high MCAT scores are people who are good at memorizing things. That's a very different skill--indeed, a very different mindset--from conducting research, analyzing conflicting information, wrestling with ambiguity.