We’ve had a number of articles on Sensible Medicine about medical education. One more in case anyone is using the site to plan a new medical school curriculum.
I agree strongly with the prior comment on critical thinking. If the individual has not had a true liberal education with philosophy etc, it may be too late to teach critical thinking?
Medical school is shockingly devoid of debates. That has got to be one of the best ways to teach critical thinking. Covid masking, gender stuff, cancer drugs. The field is rife with controversy worthy of debates based on studies.
I strongly wish that we decrease Organic Chemistry by 50% as pre requisite to medical school, and require 1) philosophy and 2) rhetoric and debate instead.
I agree with the writer. I had some superb instructors, some in preclinical, who taught how to think through from the presentation to the pathophysiology to the diagnosis. IM faculty in particular, but also many others including residents. Saved my rump many times in practice. [Retired now after 40 years]
I did however have a few striped horses and zebras along the way when an obscure dx or alternate presentation popped up from the faded rote memory.
Another overlooked skill to begin to learn is, to use the archaic words, the "bedside manner", the interpersonal relationship that makes a potentially technical interaction into a human one and can enhance diagnostic accuracy and improve treatment. My best instructors for that were community based docs (often older ones). I fear other ideas have supplanted this.
Way, way, way back when in primary school I was rote learning. I wanted to regurgitate what my notes said or what the book said so I could pass that quiz. Middle school and high school didn't change me much. I learned so I could pass the test, the final exam, to move beyond where is was. I don't know if this type of teaching and learning came from the educational processes at the time or it's what I made up myself to get through.
This type of learning followed me to nursing school. Since I was 5 years old I wanted to be a nurse. I was focused on the prize, a white cap with a black stripe. I did anything and everything I could to pass that test, pass that semester, etc. I had to learn what the teachers wanted me to learn so I could wear that cap.
It wasn't until I got thrown into the depths of my profession that I was forced to creatively think and learn and then put it to practice. I wanted to be able to think critically but the process was so foreign to me I had to relearn how to learn which put me behind the eight ball right out of the gate.
It has taken years for me to see the forest, to hear the difference between a horse and a zebra. I think that I'm just beginning to differentiate those to the sound of an elk. I recall the what and how from my rote learning, I can now learn the why and sometimes the when because I can finally see the true number of pieces to this puzzle as I put it all together.
I'll end with a controversial thought that there is something to be said about the old saying, "with age comes wisdom". I'm positive growing older has allowed me to creatively critique what is before me.
Conventional healthcare has lost its focus (including nursing-my profession). The whole person approach has been subjugated to a "body part" approach. Also, the focus is on symptom management instead of trying to discover the underlying cause. Medical and nursing students are taught how to use various classes of pharmaceuticals, but they are not taught how promote health and wellbeing (unless it involves more pharmaceuticals) such as understanding real nutrition science, the effects of ultra processed foods and environmental toxins on the endocrine system, etc.
I would agree that the landscape has changed greatly. Back when I was a trainee last century, you had to know the facts, cuz there was no google in your pocket. And it takes years to learn those facts. It certainly took me beyond the time of Med school itself to be able to put the facts assimilation and critical thinking bits together.
And he’s right. Btw google and AI, all the facts and differential diagnoses lists one could ever want for any given clinical presentation can be had instantly, and far better and far more quickly than any mere mortal can regurgitate.
So I would agree that modern day Med education should integrate the instant availability of rote lists, and perhaps emphasize the aspects of critical thinking and clinical judgment more.
That said, I think it’s quite a stretch to suggest that the absence of improvement in “life expectancy” can and should be laid at the feet of medical education. That is the mother of multi-causal endpoints for which the “best possible hypothetical Med education system” will only have fairly negligible net outcome effects. However, i do agree that, if we are to “change” med education, we absolutely should measure the effects of any such change on outcomes (to show that the newer thing is “better” by some metric, rather than changing for the sake of change).
One of the writer's conclusions is that "It’s no coincidence that we have failed to produce significant improvements in life expectancy despite having a boom in pharmacologic inventions." Medical education is part of the problem - but only part. In all countries life expectancy is measured across all people in the country - including people with "poor lifestyle" and people with good lifestyle (see an earlier comment). People with poor lifestyle may get sicker and die sooner than those with good lifestyle. Poor lifestyle results from many individual choices, but also from lack of resources - poverty, food, education, mistrust of modern medicine, insurance coverage, lack of appropriate care facilities and personnel --- others? Are any of these things part of the medical school curriculum? Family medicine is more directly impacted by these factors than other specialties in medicine, but doctors in all specialties cannot treat people who never come to the door, and never become patients.
So, doctors and their education and practice have some impact on life expectancy, but the impact is restricted by not being able to treat people who could benefit from care but don't get it.
I am a veterinarian practicing for 29 years and I am happy to be finishing my career soon. Veterinary medicine parallels human medicine in the loss of critical thinking, good history taking, AI generation of differentials and a conveyor belt approach to medicine that is rewarded. The basic tenet of medicine- Occam's Razor is impossible to follow in this environment.
Some veterinarians are at the stage, which I hope human medicine has tried and discarded, of dealing with one body issue at a time???- just treat the uveitis - it's an eye thing - what??
I feel at the root of all of this in all of medicine is the corporatization of medicine with private clinics following out of necessity because financially they can't compete, an algorithm in general practice that follows treat and street and a general approach to everything in medicine and everything else that is fine with AI non-critical thinking in problem solving. It's all about the money in medicine and to no fault to a lot of practitioners who have no control over it and wished it wasn't- it's very hard to climb out of now - unfortunately universally we need to accept medicine practiced at 70%, not 50% (the patient or the client:) will complain) and certainly not 90% -which is no longer rewarded- it's fiscally not possible and only a small population of patients/clients will recognize 70% vs 90% given what all of us have had to accept universally. It only makes sense that education will follow the same algorithm.
How above it we ask the (leg swelling) patients about their crappy diet/lifestyle and see what that has to do with their problem. Oh right, not one word about nutrition, mea culpa.
I'm not an MD, but I did visit a teaching hospital years ago for a medical procedure. The students seemed intent on impressing the attending. I wasn't impressed. In more recent times, a couple of visits to a non-teaching hospital left me enormously impressed by the docs and nurses. All wonderful!
Lots of good points in this article. But I think that medical school is a little late in the educational process to be learning critical thinking skills. The failure to develop this mode of thought is largely the fault of the entire educational system. The devolution of the culture with the deliberate attack on the institution of the family probably plays a role as well.
I did not realize Anki cards were so commonly used. I googled the topic and found how to convert a lecture to Anki cards. Not only does memorizing these bits mean you miss the forest for the trees, I suspect little of what is learned by Anki cards is retained after the test. Better to focus on concepts and critical thinking than memorize factoids. It reminds me of reading certain novels in highs school. Instead of being tested on what the author was trying to say, the questions were "what was the name of Lady Janes first cousin".
This would have been all too familiar to the late Richard Feynman as 'cargo cult medicine' in this case. He described the phenomenon when he went to Brazil to teach physics. Students memorized the words and lines from the textbooks but had no understanding of the actual concepts behind the words. They performed well on exams but were dysfunctional when it came to real understanding.
I agree strongly with the prior comment on critical thinking. If the individual has not had a true liberal education with philosophy etc, it may be too late to teach critical thinking?
Respectfully
Dr Casey
Medical school is shockingly devoid of debates. That has got to be one of the best ways to teach critical thinking. Covid masking, gender stuff, cancer drugs. The field is rife with controversy worthy of debates based on studies.
I strongly wish that we decrease Organic Chemistry by 50% as pre requisite to medical school, and require 1) philosophy and 2) rhetoric and debate instead.
This is an excellent article. The fact it is from a PGY1 is astounding. I want this intern on my team.
I agree with the writer. I had some superb instructors, some in preclinical, who taught how to think through from the presentation to the pathophysiology to the diagnosis. IM faculty in particular, but also many others including residents. Saved my rump many times in practice. [Retired now after 40 years]
I did however have a few striped horses and zebras along the way when an obscure dx or alternate presentation popped up from the faded rote memory.
Another overlooked skill to begin to learn is, to use the archaic words, the "bedside manner", the interpersonal relationship that makes a potentially technical interaction into a human one and can enhance diagnostic accuracy and improve treatment. My best instructors for that were community based docs (often older ones). I fear other ideas have supplanted this.
Well written. Seems unlikey though that this will ever happen.
Way, way, way back when in primary school I was rote learning. I wanted to regurgitate what my notes said or what the book said so I could pass that quiz. Middle school and high school didn't change me much. I learned so I could pass the test, the final exam, to move beyond where is was. I don't know if this type of teaching and learning came from the educational processes at the time or it's what I made up myself to get through.
This type of learning followed me to nursing school. Since I was 5 years old I wanted to be a nurse. I was focused on the prize, a white cap with a black stripe. I did anything and everything I could to pass that test, pass that semester, etc. I had to learn what the teachers wanted me to learn so I could wear that cap.
It wasn't until I got thrown into the depths of my profession that I was forced to creatively think and learn and then put it to practice. I wanted to be able to think critically but the process was so foreign to me I had to relearn how to learn which put me behind the eight ball right out of the gate.
It has taken years for me to see the forest, to hear the difference between a horse and a zebra. I think that I'm just beginning to differentiate those to the sound of an elk. I recall the what and how from my rote learning, I can now learn the why and sometimes the when because I can finally see the true number of pieces to this puzzle as I put it all together.
I'll end with a controversial thought that there is something to be said about the old saying, "with age comes wisdom". I'm positive growing older has allowed me to creatively critique what is before me.
Conventional healthcare has lost its focus (including nursing-my profession). The whole person approach has been subjugated to a "body part" approach. Also, the focus is on symptom management instead of trying to discover the underlying cause. Medical and nursing students are taught how to use various classes of pharmaceuticals, but they are not taught how promote health and wellbeing (unless it involves more pharmaceuticals) such as understanding real nutrition science, the effects of ultra processed foods and environmental toxins on the endocrine system, etc.
Interesting piece.
I would agree that the landscape has changed greatly. Back when I was a trainee last century, you had to know the facts, cuz there was no google in your pocket. And it takes years to learn those facts. It certainly took me beyond the time of Med school itself to be able to put the facts assimilation and critical thinking bits together.
And he’s right. Btw google and AI, all the facts and differential diagnoses lists one could ever want for any given clinical presentation can be had instantly, and far better and far more quickly than any mere mortal can regurgitate.
So I would agree that modern day Med education should integrate the instant availability of rote lists, and perhaps emphasize the aspects of critical thinking and clinical judgment more.
That said, I think it’s quite a stretch to suggest that the absence of improvement in “life expectancy” can and should be laid at the feet of medical education. That is the mother of multi-causal endpoints for which the “best possible hypothetical Med education system” will only have fairly negligible net outcome effects. However, i do agree that, if we are to “change” med education, we absolutely should measure the effects of any such change on outcomes (to show that the newer thing is “better” by some metric, rather than changing for the sake of change).
One of the writer's conclusions is that "It’s no coincidence that we have failed to produce significant improvements in life expectancy despite having a boom in pharmacologic inventions." Medical education is part of the problem - but only part. In all countries life expectancy is measured across all people in the country - including people with "poor lifestyle" and people with good lifestyle (see an earlier comment). People with poor lifestyle may get sicker and die sooner than those with good lifestyle. Poor lifestyle results from many individual choices, but also from lack of resources - poverty, food, education, mistrust of modern medicine, insurance coverage, lack of appropriate care facilities and personnel --- others? Are any of these things part of the medical school curriculum? Family medicine is more directly impacted by these factors than other specialties in medicine, but doctors in all specialties cannot treat people who never come to the door, and never become patients.
So, doctors and their education and practice have some impact on life expectancy, but the impact is restricted by not being able to treat people who could benefit from care but don't get it.
I am a veterinarian practicing for 29 years and I am happy to be finishing my career soon. Veterinary medicine parallels human medicine in the loss of critical thinking, good history taking, AI generation of differentials and a conveyor belt approach to medicine that is rewarded. The basic tenet of medicine- Occam's Razor is impossible to follow in this environment.
Some veterinarians are at the stage, which I hope human medicine has tried and discarded, of dealing with one body issue at a time???- just treat the uveitis - it's an eye thing - what??
I feel at the root of all of this in all of medicine is the corporatization of medicine with private clinics following out of necessity because financially they can't compete, an algorithm in general practice that follows treat and street and a general approach to everything in medicine and everything else that is fine with AI non-critical thinking in problem solving. It's all about the money in medicine and to no fault to a lot of practitioners who have no control over it and wished it wasn't- it's very hard to climb out of now - unfortunately universally we need to accept medicine practiced at 70%, not 50% (the patient or the client:) will complain) and certainly not 90% -which is no longer rewarded- it's fiscally not possible and only a small population of patients/clients will recognize 70% vs 90% given what all of us have had to accept universally. It only makes sense that education will follow the same algorithm.
How above it we ask the (leg swelling) patients about their crappy diet/lifestyle and see what that has to do with their problem. Oh right, not one word about nutrition, mea culpa.
I'm not an MD, but I did visit a teaching hospital years ago for a medical procedure. The students seemed intent on impressing the attending. I wasn't impressed. In more recent times, a couple of visits to a non-teaching hospital left me enormously impressed by the docs and nurses. All wonderful!
Lots of good points in this article. But I think that medical school is a little late in the educational process to be learning critical thinking skills. The failure to develop this mode of thought is largely the fault of the entire educational system. The devolution of the culture with the deliberate attack on the institution of the family probably plays a role as well.
I did not realize Anki cards were so commonly used. I googled the topic and found how to convert a lecture to Anki cards. Not only does memorizing these bits mean you miss the forest for the trees, I suspect little of what is learned by Anki cards is retained after the test. Better to focus on concepts and critical thinking than memorize factoids. It reminds me of reading certain novels in highs school. Instead of being tested on what the author was trying to say, the questions were "what was the name of Lady Janes first cousin".
Wow, that way of teaching novel is so so bad. Incredible.
This would have been all too familiar to the late Richard Feynman as 'cargo cult medicine' in this case. He described the phenomenon when he went to Brazil to teach physics. Students memorized the words and lines from the textbooks but had no understanding of the actual concepts behind the words. They performed well on exams but were dysfunctional when it came to real understanding.