How many articles start with the author realising, then lamenting, that he is getting old? Although this may read like yet another, I’m not sure that it is. To start with, I’m thirty-six. So it would be a wee bit pretentious to claim early mid-life crisis status (oxymoron though that is). So that is not what this is.
I’m writing about doctors. I am a doctor. At one stage I wasn’t sure if I would end up as one, since I spent much of my time at university involved in student politics and teaching myself Portuguese so I could chase Goan and Brazilian skirt. Alas, said skirt remaining firmly in the “down” position, I finally ended up doing some study and graduated near the bottom of my class. Although at the time I felt as enthusiastic about attending a medical ward round as did the patient in such a bedside teaching experience (that is, not at all), I now cautiously admit that I feel a fond nostalgia for my clinical medicine training experience.
The routine goes, or rather went, a bit like this: one of the consultants would hunt down a patient with an interesting disease, a boring disease with classic signs, or both, and then ask their permission (or not) to invite ten students to stand around them taking turns to poke and prod them, then speak about them as if they weren’t there. Ah yes, I can already feel the warm inner glow radiating from my progressive colleagues today, thinking that I’m about to launch into some kind of laudable tirade against orthodox medical training, how it ignores patients’ feelings and so on. Sod that! I’m writing about my feelings. No, this is about humiliation of medical students in front of their peers; and how that is a good thing.
“Please ask the patient about her problems, Mr Ayling.” The teaching had begun. The consultant was a real-life professor, with a long white coat, bouffant grey hair, and a touch of manic depression.
“Okay. Mrs Tichborne, what’s brought you into hospital?” I gingerly started.
“A bloody ambulance, what do you think?” interjected the professor. “And what’s this ‘okay’ rubbish? I know you’re okay, but this is about the patient in the bed, not you!”
Not the best beginning then. For the next ten minutes I stumbled through, trying to ask her questions, being interrupted by the professor to scold me for interrupting the patient; forced to justify every word I used in the history, compelled to hold myself accountable for every symptom I recounted or sign I claimed to elicit.
At the end of the history, examination and presentation he asked me, “So, Mr Ayling, what do you think is wrong with her?”
“Well, in my opinion …”
“Mr Ayling”—I was used to the interruptions now—“you will not have the right to give anyone anything so esteemed as an opinion until well after you have graduated. Just tell me what you think is wrong with her and we’ll move onto the next student.” The next student was by then quite pallid.
I hated those rounds. How overbearing and officious I thought the consultants were. The senior registrars weren’t much better. Although I must say that the whole experience would have been inordinately more tolerable had I read the books well in advance of the round. Even the line about ambulances was in the book (and the book in question was written by the professor himself). That is to say, if I had done some work, it would all have been easier to deal with. But that is not my point.
You see, now I am a specialist anaesthetist at a teaching hospital as well as in private practice. Not long ago I was preparing a patient for surgery to the knee by injecting local anaesthetic around the nerve supplying that region. We often do this by applying a small electric stimulus near the nerve and looking for the twitch of muscles supplied by that nerve. There was a fifth-year medical student in attendance. This wasn’t one of those teaching rounds, he was just there to watch and learn a thing or two. So I asked him, “Which muscle or muscles should I be looking for twitches in when I stimulate the femoral nerve?” I thought that was innocuous enough. In traditional anatomy training at medical school everyone starts at the top of the lower limb, in some detail. He was silent. “Well?”
He said, “I’m not quite sure.”
That was unexpected. Maybe he was nervous. I’d make it more straightforward then: “Can you tell me which muscles are innervated by the femoral nerve?”
“Can you list any structures from which the femoral nerve supplies sensory input?”
What to do? I’d make it really simple. “They’re operating on the knee. Does that give you a clue?”
“Oh yes, it provides sensation to the knee.”
“Great!” (It’s important to stay positive.) “So what about the quadriceps muscle?”
“Oh, yeah, that too.”
In case you thought I was harassing him for not thinking of scorpion sting in pancreatitis or some other petty detail, this is basic stuff. Fortunately for me, I was nice to him and he was a stout-looking man who I suspected could take some feedback without feeling oppressed.
This is where this article starts to read like yet another grumpy old man whingeing about how things used to be. I only graduated in 1997, but since then there have been some fundamental changes in medical education. There has, in most universities, been a move from the traditional model of learning scientific disciplines first (anatomy and histology, physiology, biochemistry and pharmacology), then what goes wrong with them (pathology) to learning how to treat them (medicine, surgery, and smaller disciplines). The latter phase, constituting close to 60 per cent of the total training time, was conducted on hospital wards and in theatre. I will be criticised for saying this, but medical education has been progressively morphing from a scientific discipline into a trade course.
I’m not certain where the academics thought the problem lay with the traditional system. Perhaps it was the cost associated with a six-year course (an inevitable consequence of the well-meaning state sticking their noses in and offering free or heavily subsidised university education). Maybe it relates to a perception that as applied scientists, doctors were perceived, or felt to be perceived, as stiff and uncaring, so a more sensitive course focusing on didactically learned patient empathy was preferred. I’m told that the licence for issuing a medical degree now lies not with the university but with the Australian Medical Council, which has pressures of workforce numbers added to its original mission of standards oversight for the profession in general.
The new genre of medical syllabus, called problem-based learning (PBL), now focuses, if the word focus is appropriate, from the first day of medical school, on each patient’s individual problem. A tutorial might go along the lines of a patient presenting with shortness of breath. The students then have to diagnose the problem, with the help of a tutor, but without first having spent any time on cardiovascular or respiratory anatomy or physiology, nor on pathology. They do it all as they go along. If that seems like an incredible feat, then perhaps it is. From what I can gather from current students and recent graduates, it is left up to the student to determine what to look up and study. Tutors provide some guidance. The idea is that, piecemeal, they learn all the basic science along the way and synthesise it into a system of holistic knowledge of the body. The hope is that by directing study towards clinical scenarios, the students don’t “waste” time on extraneous details that they will never use in patient care. But medical students, like any other students, are in university with a mission: to pass exams. Most will study what they learn (from observation and talking to other students) is necessary to get through the exams.
The problem is that what is considered extraneous to some is essential to others. There have been rumblings from the surgical college for some time now that new surgical trainees’ learning curve, in this case for anatomy, is steeper than it needs to be, as the knowledge of anatomy required for surgery hasn’t changed, but the starting point for learning it has. Surgical anatomy used to be revision, but with more detail and new knowledge of variations. Now it is to varying degrees a new subject. The same applies to physiology for anaesthetic training. I have heard that in some courses anatomy is an elective subject.
Whatever the reasons behind the changes—budgetary, workforce pressures, or simply viewing the profession through the filter of a postmodern uber-egalitarian worldview—the results are the same: universities are graduating less-capable doctors than they used to. The unilateral declaration of certain areas of knowledge to be unnecessary, coupled with the pressure to produce more doctors, is producing a suboptimal physician.
In not too recent history, a newly graduated doctor had enough knowledge and skill to deal with a variety of acute emergencies, diagnose uncommon but well-documented conditions, and even conduct independent research. I believe that this is because they were taught the scientific method first and clinical applications second. No matter how well a doctor empathises with patients, regardless of their ability to glean an history from a shrugging teenager or comfort a dying octogenarian, a doctor is (or ought to be) a scientist. As we used to say at medical school, “medicine is the art of knowing”.
One example of frustrations in dealing with this is a conversation I had with a graduate of a university that has been teaching by PBL for some years over the use of generic or trade names for drugs. She retorted that, “In this day and age we shouldn’t have to insist on using chemical names for drugs when the trade name will do.” Exactly what it is about “this day and age” that relieves us of the obligation to express ourselves precisely eluded me. But in one way I think she’s right. She’s not right about there being no need to use generic names for drugs, but she is right that there is something different about this day and age. What is different is the pervasive influence of postmodernist thought patterns that imply that to use accurate words like dextropropoxyphene or metronidazole may be perceived as condescending to nurses and other paramedical hospital workers who only know the words doloxene or flagyl. The need not to appear hierarchical outweighs the necessity of accurate professional communication.
Which brings me to humiliation and what is so good about it. It isn’t always good, but it can be used carefully to teach accountability. They’re only students, so they won’t kill anyone on a ward round through being wrong, but if they are wrong on the other side of graduation they might indeed kill someone. As well as a pat on the back for getting something right, aspiring doctors need to feel uncomfortable not just about getting something wrong, but also in their inability to account for how they arrived at their conclusions. In any intellectual endeavour—and medicine is supposed to be one—you have to back up your claims. This is why in my training it was drilled into us that if you don’t know something, better to endure the shame of not knowing than the sin of trying to cover up. We could not fool our professors; eventually we stopped trying. But in the feel-good hopey-changey world of left-leaning postmodern academics, admonishing someone for intellectual laziness on a ward round would be considered harassment, eliciting disciplinary action. Not to worry at all that a culture of comfort with ignorance may develop; just as long as their feelings aren’t hurt.
Doctors are human. They make mistakes. That will not change. But like pilots or military officers, our mistakes can kill. And even though most errors seem to be the result of a cocktail of systemic failures, a sense of shame at making errors, and a fear of ostracism or other censure at making them, are still a part of human nature, important in engendering a commitment to excellence. That sense of shame used to be instilled throughout our whole life, and was continued into medical training. Alas, it has waned in medicine, and even at military officer training institutions. At least it hasn’t made its way into aviation yet. I hope.
Dr Michael Ayling is a specialist anaesthetist in public and private practice in regional New South Wales.