Let's go back in time to explore the history of medicine a bit, shall we? Not too far, mind you -- a hundred years should be plenty (keep in mind that a century is a shorter period of time than some people have been alive). Back then, in 1912, medicine was absurdly primitive compared to what we have now, and frankly, about the only subjects that have stayed the same since then are anatomy and the rudimentary basics of human physiology.
To give you some flavor of medicine in 1912:
- Diabetes? Yeah sorry, insulin won't undergo its first trial until a decade from now...
- High blood pressure? Um ... the first orally active vasodilator for treating that won't come along until the 1930s...
- Big infection? Penicillin hasn't even been discovered yet, and won't be for a decade and a half. Hope you have your will written out...
- Heart attack? Well ... not much we can do to stop its progress...
- Stroke? TPA won't be discovered until the 1970s...
- Trauma? Pray...
- Oh, you have a cold? Sweet, finally, something we can do for you! Get lots of rest, drink plenty of fluids, and take some aspirin (fortunately, this had been invented by 1912). Maybe some chicken noodle soup?
The rather interesting corollary of being in such a naive field was that with enough study and effort, it was entirely possible to learn almost everything there was to learn in the entire field of medicine.
Unfortunately, this mindset has stuck with us for longer than is perhaps appropriate, particularly in light of medicine's exponential rate of growth and advancement in the last hundred years. The mindset has also developed a touch of arrogance, leading to the rather unfortunate repercussion of some older physicians scorning their younger colleagues as they struggle to learn the gargantuan amount of knowledge that medicine encompasses.
The disconnect is this: older practicing physicians have had twenty, thirty, even forty years to organically grow their knowledge base as new discoveries are announced and science progresses. How is it remotely fair, then, to mock current students for struggling when we have only the luxury of four years to cram in twenty, thirty, and forty years of additional medical knowledge...? Modern-day medical education has increasingly become a game of finding who is the better savant.
Admittedly, medical students are not expected to learn everything (that is folly), but the amount of material that is considered "basic" has grown an astonishing amount even in the last ten years. Sooner or later, we're going to lose this game.
I have in my possession two editions of a review book for the USMLE Step 1 Exam, the first of three required tests for medical licensure in the United States. One is from 2000, purchased off Amazon for $2 on a whim. The other is from 2011 and is what I used to study when I took the test myself.
Here are some examples of the differences in amount of material:
- pharmacologic management of diabetes -- 2000: regular insulin. 2011: regular, lispro, aspart, NPH, glargine, detemir insulin.
- schizophrenia -- 2000: no mention of neurologic basis or subtypes. 2011: condition is associated with increased dopaminergic activity in the brain, as well as decreased dendritic branching. 5 subtypes of the condition: paranoid, disorganized, catatonic, undifferentiated, residual.
- common chromosomal translocations for cancers -- 2000: no mention of these genetics. 2011: t(9;22) = CML, t(8;14) = Burkitt's, t(14;18) = follicular lymphoma, t(15;17) = AML M3, t(11;22) = Ewing's sarcoma, t(11;14) = mantle cell lymphoma
- sheer size -- 2000: 255 pages of material. 2011: 485 pages of material.
Medical students memorize plenty, trust me. Resorting to Google should not be considered a sign of weakness; it's simply a sign of just how much knowledge there is in the world, and the fact that four years is not enough time for everything.
Does this mean, then, that with so much information, that the medical students of today will be horrible doctors, because there is no way to learn it all?
No. We need a pragmatic change of mindset: the days of the all-knowing generalist are over. Every physician should be considered a specialist in their own right. Each doctor has their piece of the knowledge pie that they practice. This is not the sign of a bad physician. It's just reality. A board-certified dermatologist is not the doctor you want in an operating room taking out an 8-year-old's appendix. Similarly, a board-certified urologic surgeon does not have the neuroradiology training required to read brain MRIs with confidence.
What this translates to in terms of medical student perspective is simply that we learn as much as possible, realizing the limitations of time, patience, and need for sleep. We are blessed to live in an era where information is easy to access, and so we use that tool to augment our capabilities whenever possible. The things we use repetitively, whether it be lab values or basic life support, we memorize thanks to practice. But the exact chromosomal breakage site for a condition that occurs in 1 in 120,000 patients? I think I'm comfortable leaving that alone and looking it up as needed, thanks.
If memorization was all it took to be a good medical student or doctor, then it would be an absurdly simple job. But that's not what this is about, is it? When I meet patients, I have maybe ten to thirty seconds to gain their trust to let them feel comfortable discussing every part of their body with me. That's not a skill based on memorization. I have been asked to help with a patient screaming at his nurse and gathering his belongings to walk out, upset at being blown off for the fifth time as someone looking to score pain pills; not only did I manage to get him to sit and chat with me, we worked together to discover that he did, in fact, have legitimate pathology causing his pain. I did not rely on anything I'd memorized to achieve this result.
I could go on.
But let's stop and leave it at this: to judge the talent of a medical student or physician solely by the size of their memory is moronic.
 Back in 1912, the three to seven years of additional post-medical-school training we now know as "residency" wasn't even a requirement, with most graduates simply completing some internships. The current system of matching all medical graduates to residencies didn't get formalized until four decades later in 1952.More questions on Doctors:
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