Sunday, February 25, 2007

How to learn medicine

It can be difficult being a medical student. I remember having at least twice as many timetabled teaching sessions as my non-medic friends and there was a huge amount of stuff to learn. Sometimes I felt like I was using my brain purely to stuff textbooks into instead of to think with. The practicals were better although some of the physiology ones seemed to be mild forms of initiation ritual. We did a lot of carefully measured breathing and urinating in them.

I did a traditional style course, something the Angry Medic is battling through at the moment and wondering if one of the shiny new style integrated PBL based fashionable courses would have been a better choice. I can’t really say because I haven’t done one, but before the traditional style course gets chucked out like those Dallas style shoulderpads at the end of the 80s, I’d like to remember the good aspects of the course.

Most of the time there was only one textbook to consult. When I was learning anatomy I looked in the anatomy book. Simple. None of this trying to learn the anatomy, physiology, pharmacology, pathology and treatment of a heart attack all at once. It also meant we had anatomists teaching us anatomy, pharmacologists teaching us pharmacology etc unlike having a pathologist trying to teach you about all the medical aspects of a hernia. By the time we were let loose on patients we already knew where their organs were and how they worked and a bit about how their drugs worked, it might not seem much but it helps.

But the best bit was when it suddenly all made sense; sometime in third year the reason for learning everything I’d learnt before became clear. Maybe it was a long time to wait but so what. We were in a teaching session with one of the cardiologists, who took us to see a patient who had been admitted with chest pain a few days before. The cardiologist asked us what conditions could cause chest pain. Er…heart attack….er…..angina. We didn’t do too well until she told us to think of all the structures in the chest that the pain might have come from and now we were back to basic anatomy. It was suddenly much easier. It could be pain from the heart (MI, angina), oesophagus (oesophagitis, reflux), pericardium, pleura (pleuritis, pneumonia), ribs, chest wall muscles, nerves (shingles), costochondral junctions etc. Basic physiology told us why the patient might have gone into heart failure after a heart attack, and a bit of pathology and pharmacology explained the use of aspirin and nitrates. The knowledge was there in our heads and now it was time to do something with it.

The basic sciences are vital. I don’t know if they are covered as well in new integrated courses or sidelined in favour of communication skills. Surely part of being able to communicate with patients is having something useful and accurate to tell them about their illness, why it has happened, why it causes the problems they are having, what you are going to do about it and what is going to happen to them. Or maybe even why you don’t yet know what the problem is, what it might be and how you’re going to find out.

The best way of teaching medicine is still causing controversy and there are various discussions on doctorsnet (if you have access) about different courses and different medical schools. But if you walk down the street in the UK you’ll see some 80s fashions are coming back again. maybe medical courses just follow fashion too.


At 12:11, Anonymous Sinnerman said...

I'm a 'mature' student in the first year of a graduate entry 4 year course in england. The first year is mainly PBL based.

I've found PBL to be an excellent way of learning, putting information into some kind of context makes it easier to understand and therefore retain. When second year students from our course have joined the third years of the traditional course on the wards they have been shown to be at least as knowledgeable, with the added benefits a few years extra maturity can bring.

I find the 'integrated health sciences' frustrating. I think its important for us to understand sociology etc to some degree, but I find myself having to memorise various sociological models to regurgitate in exams then forget them immediately which seems to be contrary to the whole ethos of PBL. While the concepts may be valuable, I question the worth of knowing sociological models of consultation, drug taking etc intimately.

I know I wouldn't cope on a traditional course though. I am not a 'crammer'; I need to process and understand information before I can remember it and so PBL suits me a lot better.

At 20:57, Blogger HospitalPhoenix said...

PBL is a method which has an evidence base for graduate medical students, not undergraduates. Unfortunatley there are non-medic tree-huggers taking over the planning medical courses, who don't value evidence based practice, and prefer to fill medical courses with their psycho-social nonsense. There was a thread in AYV over at DNUK started by Crispin Best on the issue, if I recall correctly.

By the way - I totally agree about the parts of the jigsaw in medicine. it all seems a mystery until you've learned each part, then suddenly you realise that when someone asks you the causes of (eg) obstructive jaundice, you can work them out based on your knowledge of anatomy, physiology and biochemistry of the biliary system.

At 21:25, Blogger The Angry Medic said...

Thanks for the plug, Dr K!

This post, as well as HP's comment above, has given me more food for thought. I suppose it's true that learning all the different sciences gives you a bigger picture, but only if you can integrate it. The new courses do that for you sometimes.

I still don't know which the best way is, though I suspect it has a lot to do with personal preference...

At 03:22, Blogger Dr No No said...

I'm still waiting for all the pieces to fit....LOL...whoops probably shouldnt admit that really...but then I was one of the guinea pigs in a "top london medschool" (or so they think) when they first brought in the comm skills cr*p and took out anatomy and useful stuff...kinda shows too...

At 17:39, Blogger Dr K said...

Hi guys

I agree it depends on what suits individual students. PBL may well be better for mature or graduate students but for people coming straight from school 6th forms it might not be the best teaching method to start off with. I think I would have struggled with PBL as a new med student at 18. If I went back now I might get on better with it.

The other difficulty is what is being taught as well as how it is being taught.

I do think that evidence based medical education is important as you say, HP, and I should get searching for some of the literature on the subject (amongst all the other stuff I should be doing!)

At 18:00, Blogger HospitalPhoenix said...

Have a look for some of the studies from McMaster University in Canada, they ran the original PBL course (a 3yr 10mth course for grads) but as far as I know have now stopped doing it.

I should probably read up on it again too!

At 18:28, Blogger Cal said...

Hmm. I personally did not enjoy PBL a lot. Sure, it was very useful, but to have an entire course based mostly on PBL would do my head in.

A key factor determining the success of a PBL session lies in the group dynamic. I thought that the group dynamic in my group was not very motivational or collaborative. Everyone had a different agenda, and as a result, some learning outcomes usually weren't acheived.

I prefer my medical school's way of teaching. We have a good grounding in pharmacology, sociology, biochemistry, anatomy and physiology, and then we move on to the clinical things.

I've found that on the wards, things are finally beginning to click and lock into place. I really enjoy that aspect of it.

At 13:37, Blogger Dr K said...

Hi Cal

I can imagine if you have a group with the right combination of people in then PBL would work a lot better than a group with a bad combination of personalities. I'm glad you're enjoying life on the wards, it's good when you're part of a clinical team.

At 10:12, Blogger ditzydoctor said...

hullo! where i come from, we have both PBL and traditional teachings. PBL is a supplementary thing, about 10 sessions per semester. it does help in keeping interest alive, especially when you're in the basc sciences years and bored to death of cramming anatomy and physiology to stuff your brain. but when i stepped into the wards in yr 3, all that i knew came from traditional teachings and remembered nought from PBL sessions. so hooray for the traditional way! it's really lovely feeling things click! =D

At 13:08, Blogger Arslaan said...

Hi I am a as student and after this summer i have am going to apply for medicanin universites so i am not sur what what course to goo for pbl or tradition can u guys commment a bit more on this issue...:)

At 00:14, Blogger Grazina said...

I think that the problem starts much earlier, in primary school. When I was in primary school we had a very structured curriculum, with manuals to follow from cover to cover, many books that we have to read and homework every day.

Biology as they teach it at school now seems to be part of "science", and here's the information for parents about it:
"Science is a mandatory course that to be studied substantially in each of Years 7–10 with at least 400 hours to be completed by the end of Year 10.
Course description
Science develops students’ knowledge, understanding and skills in making sense of and explaining the biological, physical and technological world, enabling them to make informed choices and responsible decisions as individuals and as part of the community."

That means that you learn biology and technology at the same time and the same person teaches both! Not to mention that the same teacher is required sometimes to teach English or physical education as well.

I calculated how many hours a week they teach that combined “science” and I was shocked! We had in primary school and high school 1-2 hours per subject every week, and – just like Dr K says – we had a biologist teaching us biology and a mathematician – mathematics. All the subjects were mandatory, with tests every week. Additionally, biology was not “biology” with bits and pieces of other stuff, we were taught basic biology – including anatomy, biochemistry, cell biology and genetics one year, then botany in next grade, zoology next year, then human biology next.

So when you were going to uni you already had good basic knowledge, and it was much easier to go to the next level. Sometimes I feel that the people who design education system now treat children and teenagers like idiots and they waste 12 years of their life. In fact, my son’s teacher in primary school told me that I worry unnecessarily about his education because he’s at school “not to learn but to socialize.” I’m not kidding.

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