Thoughts and opinion from the wards
Fact based learning and opinion based practice
This is my open letter to my nieces one of whom enters and one leaves med school this year.
Dear Sam and Mayank
Congratulations. Sam you have done well to get to med school. Mayank you have done great and will finish med school later this year. You are in the top 2% of the academic performers and you will continue to remain there at least till you begin independent clinical practice, hopefully many decades into your clinical practice.
I write this in joy but more relevantly to provide you another window for your intellect and for your practical development.
I did Anatomy, Physiology and Biochemistry in my first year at med school. There are not many more accurate and fact based subjects than these in medical education. Fact after fact, learnt day after day. We realised that these facts were the foundations of our future careers, we took it really seriously. We demonstrated our mastery (okay, personally I just demonstrated my mere competence) by passing tests and exams. It was tough. It was worth it. I was satisfied that my foundations were good.
These fact based subjects left an indelible impression in my mind that medicine and its practice was based on accuracy and facts. When the facts varied, such as when the cystic artery was double or it was low lying and so on, they were grouped into sub-facts to be remembered for future reference and practice. Some facts were actually a range of facts as in the normal range of plasma sodium values and so on. Later on while attending physiology classes at the Royal College of Surgeons at Edinburgh, the tutor would squeal in dominant delight ‘either you know it or you don’t’; no more powerful, explicit message for post-graduate doctors about the need to be precise and accurate. A message that I heard many years earlier in first year med school and repeatedly thereafter.
As we moved along we recognised that subjects like pathology and microbiology begin to interfere with subjects like anatomy and physiology and gives rise to trouble in real people. Help was at hand for us to understand that. Pathology text books showed clear microscopic slides on how every pathology looked, again where there were variations they were classified as yet another group of facts. I got the impression at that time that if that’s how it looked, that is what it must be. That kind of thinking was compatible with the fact based approach of anatomy and physiology. All this knowledge was then put to practical use by learning even more glamorous and glorious subjects such as surgery, internal medicine, gynaecology, et al. Those were exciting days.
We continued to learn from revered text books on the one hand and from revered teachers on the other. Patients had clinical problems, we used our knowledge to diagnose them (CT scans were extremely rare when we were medical students and ultrasound scans were just taking off and x-rays in general provided basic support) and applied our knowledge to treat them. Of course things did not always go well for patients, we still call them complications or morbidity, sometimes patients died, we classify that as mortality.
As we gained experience often as post-graduate doctors we began to realise that all of our revered teachers did stuff very differently from each other while they were dealing with similar problems. The cleverer of the lot justified their different styles of practice by references to science, the rest told us that their experience suggested that their practises were valid. Our professors and consultants told us that they acquired their wealth of knowledge so that they can give their opinions. One sudden day we recognise that we learn medicine on the basis of knowledge and practise it on the basis of opinion. On the basis of very very widely varying opinion.
We begin to wonder. If the learning in undergraduate medicine was based on accurate facts, why is the practice of real world medicine on the basis of hugely varied opinion? We brush aside these discomforting thoughts. We have not only made a huge investment in our knowledge but also in our method of acquiring and practising that knowledge.
Pathology text books did not tell us that two pathologists looking at the same slide could give you two different opinions, not often but certainly possible in the definition of complex cases. We were never told that the text books that we read were by definition about five years out of date or that at worse some of the editors edited those books while travelling in their ultra-luxury cars between various locations of their private practices or at best after a couple premium alcoholic drinks in their study. We were realised that when our teachers said the words ‘in my experience’ it did not mean objectively measured operational experience but meant their personal subjective understanding of how they thought they performed.
In medical practice there is evidence for everything and there is evidence for nothing. This provoked David Eddy, the American father of evidence based practice (oh, by the way evidence based practice has two fathers one American and one British) I believe to say something like that you can find two physicians to testify in court to the exact opposite views.
Nobody will tell you yet that
Substantial activity in clinical medicine cannot after care delivery find evidence to back it
Substantial clinical care is delivered incompletely
Substantial amount of errors are found in the delivery of care
Substantial numbers of clinicians are either unable or unwilling to accept the above
These issues are not just academic, they have great direct impact on patients and their lives. We did not know at med school that there was an entity called avoidable mortality; when we first heard about it we found it unbelievable for the reason that if it was avoidable us clever and experienced doctors would have already avoided it. We did not know at med school that practice of healthcare is highly error prone and extremely unsafe; when we came to know about it we did not believe it. Despite this we and the public, trust ourselves - the medical profession; we trust our high intelligence, our extreme hard work or proven record of success for ourselves and for our profession. We are brilliant and we have faith in ourselves. The brilliance of the medical profession is also blinding itself.
The second half of the blog where I discuss how we may attempt to resolve these can be found at my regular blog
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Can you be too strong for family medicine?