Old School Advice – New School Notions

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The phrase ‘back in my day’ conjures up a tone that suggests the author is infatuated with some traditional and probably irrelevant idea that has no place in modern medical education.
Interestingly, I was no different from my currents students.  I ignored or at least didn’t emphasise the importance of the pearls that my old professors use to hand out to me.
After over 25 years of both learning and teaching I have come to increasingly appreciate the wisdom of four common pieces of advice.   They simply describe the most effective techniques for obtaining the expertise to be a clinician.   In subsequent years, these statements have been backed up by the latest theories in education and learning.
“Just go and see lots of patients”
It seems odd that after several years of being confined to classrooms, libraries and exam halls learning to be doctors, many students are apprehensive about their time on the wards and clinics.  This period should be the most liberating time of all where they can at last see how their hard-earned knowledge can be applied at the bedside.
Seeing patients has many benefits, it allows us to perfect drills such as elaborating the history of the presenting complaint using the SOCRATES (or equivalent) mnemonic, taking a proper drug and alcohol history, or practising our neurological exam until it is flawless and natural.  Although this initially may appear to be a mindless and gratuitous activity, the benefits are immense.  Once we can relegate these apparently unimaginative activities to reflexive, brainstem function we can then get on with the real job of data analysis, diagnostic reasoning and management planning.  If we have yet perfected the basic components of clinical assessment we are at risk of cognitive overload during a clinical encounter.  We end up more preoccupied with remembering what to do next after checking the  deep tendon reflexes rather than already synthesising the preliminary findings into a potential hypothesis and then determining what else needs to be done to confirm our diagnosis
The more patients we see also means the more connections we make.   We make those connections within the one patient e.g. linking their occupation with their disease or their medications and cormorbidities with their side effects, their condition with the treatment.  There are also links between two patients with fairly similar problems but often different treatments (no patients are ever exactly alike in age, sex, co-morbidities or in response to treatment).  There are also connections to be made with patients with apparently unrelated complaints e.g. the risk factors for one patient’s angina is exactly the same for another patient’s intermittent claudication and the same for the one who may have both!
As your repertoire increases, so does the strength of your memory connections.  Connectionism is the concept that we understand the world better when we see how all the different components link up.  This is to be distinguised from connectivism where we see how raw knowledge is applied and modified in a social and cultural context e.g. the theory of the grief reaction and watching a doctor break bad news.  Thankfully at the bedside both of these learning theories are applied regularly.
“Read around your cases”
Seeing patients not only provides lots of skills practice, it provides the exact context for exploring the really important questions that need to be sought from textbooks. No longer is study based on having to mindlessly regurgitate random facts as done for exam preparation.   It is well established that deep knowledge has to have meaning and context.  Discrete units of information such as the biochemistry of lactate is quickly forgotten unless one understands its relevance to critically ill patients.   Conversely, the reason why pulse oximetry is a poor measure of ventilation in an over-narcotised patient can be understood by the physiology of oxygen and carbon dioxide transport.   Every time you see a patient, their unique set of characteristics should provide more than enough material that should stimulate a whole range of inquiries into the why, how and when of medical diagnosis and treatment.  This process of exploring unexplained observations, considering alternative possibilities and anticipating potential problems in an essential process of generation and elaboration that creates an increasingly detailed mind map that enables one to interpret complex problems and distill them into simple principles.
“You need to have a system”
All surgeons will regularly tell you that most diseases and differentials can be generated using the Surgical Sieve.  Vitamin ABCD is a mnemonic that essentially lists the generic pathological processes by which disease can manifest.  Each of these processes, such as infection or neoplasm are associated with common manifestations and treatment principles.  However, the sieve isn’t the only system.  Resuscitationists use the ABC – Airway, Breathing and Circulation mnemonic to remind themselves of the key priorities in a critical patient.  Dermatologists use a standard pallette of descriptors for spotty rashes, bumpy rashes and blistering ones.   There are systems for remembering anatomical relationships, patho-physiogical processes, diagnostic categories, management principles and even prognostic criteria.   Systems are essentially arbitrary ‘hooks’, schemas or structures upon which you can more effectively build your knowledge and understanding that also allow for more effective recall.  It enables you to see patterns in the apparent randomness of a textbook or in a clinical encounter.  The more systems you have, the deeper you grow your understanding and the faster you can acquire knowledge.   Without systems, there are no connections.  Without connections, it is difficult to remember let alone fathom what you hear, see and do.    And without systems, you are also more likely to make random and illogical connections and consequently apply knowledge in a haphazard (and in medicine, in an inappropriate or dangerous) way.
‘See one, Do one, Teach one”
This process is often described drily in a humorous though slightly shameful manner.  It would suggest that learning medicine in our early years is acquired through ‘flying by the seat of our pants”.   Clearly, it is important that clinical procedures are taught under proper supervision but nothing beats learning than actually getting your hands dirty and being allowed a little freedom to do so.   Doing something unveils issues that are not always appreciated when watching or listening.
But the instruction has much deeper implications.  Devoting your whole concentration to watching something once is far better than several casual observations of the same thing.  With the possibility that you may be called on to the next one, suddenly our mind becomes far more alert to the minute details that we would have previously ignored.  We become more questioning and we anticipate problems and traps that we may personally encounter.   There is the concept know as the ‘Von Restorff effect’ where a novel situation  induces more psychological arousal than routine regular events.  This in turn enhances memory and recall.  This is also observed when we readily remember arcane facts and medical eponyms for the nature of their bizarreness rather than their relevance.  It is applied by skilfull eductors who ‘mix’ up the lesson with different activities.   And it is used effectively by students who change the topic of study regularly when they read.
Lastly, teaching is highly related to learning.  Although quieter students are naturally reluctant to teach in front of peers, the principles still apply whether doing it in with friends, family or in even in front of a mirror.  Preparing a teaching episode involves a reasonable amount of preparation.  Firstly, some reading is required to ensure that your facts are indeed correct.   Secondly, you need to be able convert knowledge into a easily digestible form that can be understood by the audience.   This process may already alert you that you may actually be hazy on a few details that don’t quite make sense and prompt you to do some more reading.  Finally, teaching is an example of retrieval practice.  This has been proven to be the most effective way of memorisation, far more than re-reading texts, revising notes or underling textbooks.  Without any notes or prompts, you attempt to recall the information in a meaningful way relevant to a certain context.  This usually uncovers any gaps in your understanding.   The wise teacher also rehearses their talk through deliberate practice so that information can be recalled effortlessly and naturally.  So to expand on the initial statement it would be ‘See intently, do reflectively, teach expertly’. As one educator has written, a poor memory is not a problem with remembering, it is an issue with recalling.   Retrieval practice is the antidote.
Therefore, retrieval practice and deliberate practice are not only exercised when teaching.  They can also be used in private study, during bedside evaluation and management, when providing patient advice and when communicating with colleagues and supervisors or performing a clinical procedure.
Summary
Four simple yet powerful phrases – ‘See lots of patients’, “Read around your cases, ‘Be systematic’ , ‘See one, do one, teach one’ has been advice historically given to medical students.  They are not achaic ideas but have have solid grounding in modern education theory.  Exercise all of them regularly and your path to expertise is guaranteed.
 
For the origins of ‘Lorem Ipsum’ check Wikipedia – https://en.wikipedia.org/wiki/Lorem_ipsum
 

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