It continues to astound me that a vocation that has been around as long as medicine has, continues to have so many unknowns. We don’t know the best way to teach new clinicians, the best way to measure quality, the best way to measure outcomes, or even a viable consistent method to compare clinical care between practitioners and institutions.
This is certainly not from lack of effort, but it does exemplify the incredible complexity of medical care, and the difficulties inherent in trying to teach people to effectively deliver a service with consistent results.
A big part of the issue is that “optimal” care is such a moving target. Optimal care both in and out of the hospital has changed so many times for several conditions that it really makes you wonder if what we are doing now will not be found to be detrimental in the future. ACLS and BLS are great examples of entities taught with absolute certainty 20 years ago, that now have almost entirely different care processes in 2012.
I think this is a very strong reason for decreasing the amount of factual information we ask our students to learn, and increasing the amount of tactical thinking they do. I think there is about a 0% chance that any medical textbook’s information will not be changed significantly in the next 10 years. So drilling that information into student’s heads will lead to knowledge with a potentially very short half life. However, running students through scenarios where they can identify their knowledge gaps, and then fill them, I believe, will lead to better clinicians in the future.
I did research in education for several years, and was amazed at how much was known about learning that had not made it into medical education. Only in the past 1-2 years have many medical schools begun to embrace some of this information, but we still have no good data to know if those changes are helpful.
Textbooks and multiple choice tests work well for teachers and schools because they allow teachers to give standardized tests, with standardized responses, that generate a bell curve of apparent competence. However, as the military and aviation learned, you cant have someone who knows 85% of what to do and pronounce them competent. 85% of the knowledge of how to land a plane will not work out well. Those domains demand their students to demonstrate 100% mastery of the process 100% of the time, and we should as well.
As students, it is vital that you learn to question the medical knowledge you possess. With the tremendous information access at your disposal, there is no good reason why you couldn’t Google the last 10 peer reviewed papers on diverticulitis within an hour of seeing a patient with that condition. You should then have an intelligent discussion with your teacher about why you are doing things the way you are doing, as long as it doesn’t delay emergent care. In emergent situations, following protocols is vital, but afterwards you should make certain you understand why you did what you did. Any teacher who says “this is the way we do it, because I said so” is not a good teacher, and likely not a very good clinician. Anyone who thinks they can write a care guideline that will be optimal for more than a year is probably deluding themselves. Also, be aware that national guidelines are really the “best guess” of a group of smart and experienced people. That guideline should be where you start learning and understanding what to do, not the end of it.