Is Current "Teaching" Medical Students Really "Preaching" to Medical Students?
You know, I was thinking, medical school is all about preaching to the students their Commandments toward their future practice of the profession of medicine. We are saying to them:
1. "Here are Your Tools for practice We have Chosen to be Given to You, Here is Your Medical Education We have Devised, Here are Your Standards of Practice
2.Here are Your Codes of Ethical Practice
3.You will be Monitored by Us to Graduation and by Others beyond for adherence to Continuing your Medical Education
4. Your Adherence to Standards of Practice and Codes of Ethics
5.You may Select a Specialty of your Choosing and Comfort but Monitoring for Your Adherence will Continue."
And if that isn't Preaching the gospel of Medicine, I don't know what Is?
Should we, in medical school education, really be teaching students only about the options available for taking a history, for performing a physical exam, for making a diagnosis, for providing treatment and for the overall practice of medicine including the pros and cons of various behaviors within the responsibilities of a medical doctor rather than be setting a series of medical rules which have been carried down from one medical generation to another without empiric, statistical documentation of the value or harm of each dictum?
What do you think? ..Maurice.
Graphic: Preaching from Fellowship Room via Google Images.
posted by Maurice Bernstein, M.D. @ 3:57:00 PM
7 comments
7 Comments:
The difference between teaching and preaching can be subtle and I'd have trouble differentiating them in all circumstances.
You have to teach students how to think problems through on their own while still giving them enough caveats to do no harm.
There is teaching to the students going on regarding disease (pathology, symptoms and treatment)and which is usually based on current literature. Where I see preaching is more in terms of how students learn about the mechanics of history taking and performing a physical exam and I believe that much of that is not based on educating students about alternate possibilities to consider for their own use or formal studies or current literature but on the methods which have been repeated from one generation to another without empiric or considered reevaluation. To me, that's preaching.
I found a description of what I am writing about at "1 Boring Old Man" website with the following narrative:
"Somewhere along the way in medical training, I realized that I was being taught a coherent system that had evolved over centuries, and was awed by its clarity. When I saw a patient, I was to use a time honored algorithm to approach the problem of their complaints. I was to gather a complete narrative [Present Illness] of the Chief Complaint, then check out the Past Medical History and do a Review of Systems to assess their overall health and body functioning, followed by a thorough Physical Examination. While going through this procedure and/or shortly thereafter, I was to sort the database of medical conditions for Signs and Symptoms and create a list of the conditions that fit this patient – called the Differential Diagnosis. I then resorted that database for things [tests, consultations, etc.] that would help me narrow that list as far as possible in order to arrive at a Diagnosis. Having hopefully arrived at the right place, another sorting – this time looking for Etiology, what was the underlying cause of this Disease [or diseases], and what was the Treatment for the cause [if it could be treated]. Symptomatic Treatment came after, never before, I knew what I was treating – or was close enough to be sure that treating symptoms wouldn’t get in the way of finding the cause. That’s a real Algorithm – an almost holy algorithm. It’s an indelible part of my mind and I’m grateful to have been taught it so thoroughly. There are many variations on the theme [in an emergency, do a focused version very fast], but the principle is invariant. As a medical student, I wondered why old experienced doctors seemed to skip a lot of what they made us go through so obsessively. Then I got to be an old experienced doctor and realized that they were only asking the things they didn’t already know intuitively [from having done it a blue jillion times]."
I am not proposing that "preaching" is a forbidden tool for education or particularly medical education or the medical profession but I wanted to emphasize that some of what is taught in medical school, to me, should be considered something other than just teaching. ..Maurice.
Throughout residency, I had the phrase flicker through my thoughts, "Teaching the unteachable, learning the unlearnable."
The closer one gets to the core of medical thought, the harder it is to express to another. Maimonides said something like, 'if you know little about medicine, it's easy to do. The more you know, the harder and more uncertain it gets.'
Preaching it its more negative sense is the recitation of poorly-understood concepts, for the sake of ritual, backed not by the compelling certainty of understood truth - but rather by social threats to one's conformity and status.
My medical school - Boston University - taught me well, like the Boring Old Man's wisdom above. On the other hand, I went to "Preacher U" for residency, and came out with little new that I went in with.
SteveofCaley, and what did you expect to derive and gain from your residency? ..Maurice.
As to residency, well... I consider that I had the best and worst of medical education, most of the best coming from BU and most of the worst coming from ____ State.
BU taught me a tremendous amount about humanity, mine and others, as well as a sterling job at medical education.
____ State taught me that there is, like all human enterprises, and awful side to the process of education.
It took me 10 years to come to grips with the thrashing I took from ____ State. I showed quite a bit of the PTSD habit of "don't go there, let's get on with things."
Residencies ought not to leave one with serious damage below the waterline. This one did.
Ah! To SteveofCaley, I believe I have the answer! It's all about the "hidden curriculum"--(for those readers unaware, this is the perhaps unethical and unhumanistic behavior toward patients and their workups or even toward colleagues or even students instilled which into some beginning physicians which has a tendency to destroy the ethical and humanistic behavior learned early in the student's education.) So, SteveoCaley, fortunately BU provided you with the last 2 years of med school with no "hidden curriculum" (great!!) but you were not so lucky with your later experience at ____State. Right? ..Maurice.
You are closer to the mark than you might expect. When I was an undergraduate, I went to the university bookstore and bought a remainder book named The Hidden Curriculum, by Benson R. Snyder. It's a heck of a bargain for a quarter!
Even worse, I read it and loved it! I see an e-blurb on Wikipedia that states, "much of campus conflict and students' personal anxiety is caused by a mass of unstated academic and social norms, which thwart the students' ability to develop independently or think creatively. These obligations, unwritten yet inflexible, form what Snyder calls the hidden curriculum."
Too much truth at an early age, as I also read Postman & Weingardner's Teaching as a Subversive Activity, AH Neill's Summerhill, and a few other books on teaching and conformity, during my college years. (PS: I never majored in anything related to this stuff, however.)
Lately, I've enjoyed John Gatto's iconoclastic writing on American education, and find that it has a strong ring of truth to it.
Anyhow, spot-on with the "hidden curriculum" remark!
(SteveofCaley, anonymous for software reasons only.)
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