Bridging The Divide

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Reproduced with kind permission from Placebo January 2011 Edition.

Bridging the divide
Observing medical students today, it is interesting to watch them still struggle with the same difficulties as I did when I started my degree at Adelaide University 20 years ago.  As one who easily found success at high school, the medical course confronted me with challenges that I was unprepared for.  I had no grounding in the biomedical sciences (much like many post-graduate students of today), apart from some brief exposure to organic chemistry and biochemistry.
In medical schooI I struggled with the rote-learning of anatomy.  The only subject vaguely familiar to me was medical physics.  The course advisors tried to ‘liven’ up the material with references to clinical conditions.  However, these occasional anecdotes seem irrelevant and distant to the pressing matter of passing my exams.  The sheer volume of information that needed to be memorised was overwhelming (such as reproducing the structure of the twenty fundamental amino acids).  The teaching of the social sciences was just as prominent then as they are today.  Back then ‘Community and Preventative Medicine’  (or ‘Comm Med’) maintained its consistent presence throughout the entirety of its course to the resentment of the student body.  For me things deteriorated to a point that midway through 2nd year I managed to fail all but one of my subjects.   As a 17 year old living far from family, I was seriously re-considering my career options.  Why was I making these sacrifices attempting to study information that seemed completely removed from its practical application.  My motivation to be a doctor equalled my ability to interpret the endless monochromatic series of histology slides our eyes were assaulted with each week.
The transition through the third year was still lecture based but provided some glimpses of what was crucial to our future careers – pathology, microbiology and pharmacology.   Yet the sum of this rigorous indoctrination didn’t seem to prepare me for my clinical rotations apart from the relentless torrent of facts we were still expected to absorb on the wards.    By the end of my course my overall performance could be best described as average.  I had a vague dissatisfaction that much of my efforts were misdirected and that I had not fully realised the potential of the material that was taught.  I was sure that I somehow had missed critical information that was required for success.   Yet in contrast there were some of my classmates who quickly appeared to ‘get it’ and effortlessly grasp and retain the important lessons of clinical practice.  What were they seeing that I wasn’t?  I struggled with confidence throughout my internship.
Despite this inauspicious start to my career in medicine, I worked steadily at revising my knowledge during my residency.  ‘Lights began switching on’ and my ability and confidence grew.  It was as if the old lessons were now imbued with new meaning.  Often there wasn’t an issue of not knowing but not applying.   Revising the biomedical sciences for my College Primary Exam was a chore but later in life I came to appreciate how foundational this knowledge was to my practice. I actually was unconsciously applying its principles every day.  Even the abstract ‘Comm Med’ provided important lessons and gave me a much broader view of medicine and healthcare in general.    I also learnt to conquer my old nemesis, Anatomy.  (If only I had known how to approach this subject when I first studied it!)
Over the years I have reflected on my experiences as successive generations of students and junior medical officers have passed my way.   The same pattern kept re-emerging.   Knowledge often was fragmented, connections were not made between concepts or across disciplines, clinical practice was devoid of scientific rationale and practical application was patchy and undisciplined.   What was the missing element?
The problem was no different than what I experienced two decades ago.  Clinical medicine by nature crosses many discrete fields of study (expanding with every passing year).   Attempting to usefully integrate such a wide expanse of knowledge requires a certain amount of expertise and discernment usually not available to the uninitiated.  Conversely, I anecdotally found that many doctors from ‘medical’ families often had less trouble with this.  Not because they had already acquired the requisite knowledge base but by passively absorbing an intrinsic ability from their home environment to discriminate what was relevant to their chosen vocation.  But most students do not have the privilege of such an experience.  Rarely do they have a clinical mentor to help them navigate them through the initial years of the degree and then combine this successfully and meaningfully with new material when they ‘hit the wards’.
Perceiving this deficit,  I decided to embark on an initiative to assist students through the process.   Through students contacts I have commenced a set of weekly lectures in ‘Clinical Reasoning’ for GEMP 1 students. Unfortunately the title does not do the material justice.   Its main purpose is to highlight, reinforce and combine the key areas of biomedical knowledge pertinent to clinical practice.  Contrary to popular belief successful application does not actually come from mastering each of the subjects individually.
What began with about 15-20 students each week that relinquished their Friday lunchtimes for the 2nd semester grew to over 50 people at the end of the series.  These are conducted in a fairly informal and interactive atmosphere that attempt to move seamlessly between the biomedical science and the clinical application.  There is room for questions from both sides of the lectern.  The format can vary from role-play, group problem solving to class quizzes.   The feedback so far has been encouraging.  It combines the expert content of a lecture with the interaction and intimacy of a tutorial.   Though it has a clinical bias, the biomedical aspects are embraced and there is no preferential treatment of clinical disciplines.  In fact the best received lectures draw upon a broad expanse of areas that the student has already been previously exposed to in one form all another.  For instance a lecture on blood gas determination and metabolic acidoses included a review of neurophysiology, cardiology, endocrinology, renal physiology, biochemistry, gastroenterology, gynaecology, surgery, trauma and critical care
New areas of research and disciplines are constantly developing.   This has been paralleled with the evolution of an ever increasing number of clinical super-specialties.  No where in the history of medicine has there been such a pressing need to rationalise this knowledge into a digestible form for our embryonic and undifferentiated doctors of the future.
Dr. Derek Louey MBBS FACEM
Staff Specialist
Emergency Department
Flinders Medical Centre
Senior Clinical Lecturer
Graduate Entry Medical Program
Flinders University

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