Learning vs. Reality

Regularly we attempt to learn content that is constantly in flux and subject to change, even before we learn it. This phenomenon is built into the system of education that is medical school. There is a built in delay from reality, to national board testing that almost requires that we learn "old" information in the first two years so we can "pass" a board exam that was effectively written, validated and released during the past 2 years. Confused? When I sit for my Part 1 USMLE board exam in early 2010, that information being tested will have been "current" in 2007-08...it's just how the system works to write, review, validate, test, store and assemble questions and exams.

Flash to now...I'm learning content that is both text based (in itself 2-3 years old via publishing standards) and trying to integrate that with my current knowledge and new knowledge about patient care that we read about everyday (about the only reason I'm sorry for the Internet). So as we learn about the disease of ovarian cancer, the data is in continuous flux. Today I read....

Investigators disagree about value of combination screening to detect early-stage ovarian cancer. (3/20) reported that researchers in the UK, who are conducting "the largest randomized controlled trial of ovarian cancer screening to date," are saying that, used together, "both the cancer antigen 125 (CA125) blood test and trans-vaginal ultrasound might be capable of detecting early-stage ovarian cancers." But, researchers at the University of Alabama-Birmingham maintain that the screening regimen "fails to discover the cancer in its early stages and often results in unnecessary surgery," HealthDay (3/20) pointed out.

The question is what will be current knowledge on my board exam in 2010 when I am taking the most important test of my life to get to the next stage of my medical education...rotations? This guessing game of sorts, and preparing for an exam is understandable, but a bit bizarre and more about the test than anything else. I'll learn how to be a practitioner later.

The next Bozo instructor that tells me he or she is not teaching to the test should be fired right on the spot. It's ALL about the test! I can't move to the next phase of this educational process without passing that exam. I'll learn about current ways of thinking after Step 1 (and then unlearn it a few years when I have to take Step 2). I'll learn about doctoring in my residency. In the meantime, focusing on the massive amounts of "old" content is enough. If you give me one more cutting edge study or minutiae point of information that has nothing to do with anything but showing me how much you know (or test me on it, God forbid) in this part of my education, I'll SCREAM!

Crunch

The week before exams, people change. Beyond the nervousness of the exams and content, this time there is an air of "I've got no clue how this prof tests". The field of medicine is so huge, even within the course disciplines and testing shouldn't be a guessing game. This exam, for many of us in all the terms, it is. So beyond the content, which isn't hard, is the unknown of new teachers and methods (changed mid-term). Students are more isolated, and pensive this block and frankly I don't blame them. It's crunch time...with an edge.

But I went swimming in the Caribbean today and saw my first octopus...a big Caribbean Reef Octopus. Beyond the exercise and getting the "stress" out of my shoulders and working out, the thrill of the animal was amazing. I actually spotted him when a stingray (a common sight where I was) cruised by him and they scared each other. The ballistic movement of both  threw up some sand and caught my eye. It was cool and got my mind off "crunch", even for a moment.

It Doesn't Fix Easily

I try. I really try. Every day it's a new start and an effort to work with what God gave me. Psalm 118:24 says, "THIS IS THE DAY THE LORD HAS MADE". I try to maximize all that is provided and cerebrally know that it's a blessing to have this opportunity and focus. But this system is broke and it won't fix today, tomorrow or for many, many months to come. By then I'll be gone.

Valuing Teaching

An outstanding article appeared recently in the "New Physician" journal from the American Medical Association. It sort of summarizes my frustration with the education I've witnessed here and heard about for years. But here at a "teaching" institution with minimal research, and publication pressures on faculty, I expected different. But what I realize is that school administrators and instructors who are not now, and have never been educated in "teaching" don't even know where to start. The classroom in medical school IS the "last frontier" in need of change.

MEDICAL EDUCATION VS. MEDICAL EDUCATORS

After 100 years of bold strokes, improving the training of medicine’s teachers still requires investment
The New Physician, January-February 2009  by Pete Thomson - Volume 58, Issue 1

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“Revolutionary would be if a medical school succeeded in truly valuing the teaching mission.” -Dr. Kenneth Ludmerer

**"...one element of medical education only recently began to change, and it may not change much more without support from medical schools themselves and an attitudinal shift in physician culture. That element is the recognition and promotion of teaching skill in the medical school classroom."

**“What would be revolutionary would be if a medical school succeeded in truly valuing the teaching mission.”

**"Generations of medical school faculty and administrators have held to the idea that teaching as an art is a waste..."

**"...the delusion that knowledge of subject matter automatically makes a good teacher...At the higher-education level, very few faculty are really taught how to teach."

**"...we have an obligation and responsibility to prepare our teachers to teach.”

**"...medical students are medical school consumers and, as such, are entitled to demand great teachers and great teaching. But excellence in medical teaching matters the most to the ultimate consumer: the patient population."

**"...medical education has a lot to learn about teaching..."

Nuff said...just nice to hear someone else say it.

Long Time

I know it's been a long time since my last post. Lots of stuff has happened and I've been very busy with school, but I hope that regularity will now follow.

Teachers continue to come and go. Classes are unpredictable and sometime unintelligible. School is reorganizing with new administration punctuated by school functions and events. Island life never really changes but offers peace in the form of diving and hiking for me. Looks  like we are open in Summer, but beyond that is anyone's guess.

I think it's time for some Buddhist balance and perspective.

"If we use our human life to accomplish spiritual realizations, it becomes increasingly meaningful.  Thus by using our human life for gaining spiritual realizations we can solve all our human problems and fulfill all our own and others' wishes. What could be more meaningful than this?"- Spiritually I'm still in the "right" place and finishing the basic science years is still the "realization".

"The real source of happiness is inner peace. If our mind is peaceful, we will be happy all of the time, regardless of external conditions, but if it is disturbed or troubled in anyway, we will never be happy, no matter how good our external conditions may be." - I'm not quite there yet. I still have expectations that are not fulfilled, but I'm getting better at realizing that school can never provide everything we need. How close they come is a matter or daily gradations.

"If we respond to difficulties with a positive or peaceful mind, they would not be problems for us. Eventually we might even regard them as challenges or opportunities for growth and development. Problems arise only if we respond to situations with a negative state of mind. Therefore if we want to transform our life and be free of problems, we must learn to transform our mind." - Sound so easy, but the exam we take at the end of this process is make or break, and all important. It is hard not to hang that success or failure on what happens now, but "positive and peaceful" is clearly the goal. That school can provide everything we need is a delusion, a bad mental habit, and that habit can be broken.

"Delusions are just bad mental habits, and like all habits they can be broken. With no delusions remaining in our mind, there is nothing that can disturb our inner peace and joy."  - Gyatso

Lions and Tigers and Bears, oh my!

If it's not donkeys at the airport...

or Cows in the road...

Then it's killer bees in the trees outside my apartment.

Never seen anything like it before. One moment they weren't there, the next moment they were. An the most aggressive little suckers you've ever seen. 3 of them chased a butterfly as it flew by. Poor flutterbye :(

Makes exams in 2 weeks look like a piece of cake. Hopefully bee resistant cake though.

St. Valentine, my eye!

Pulmonary Edema

"Pulmonary edema is not a hydrostatic phenomenon!"...that's what he said to justify the exam question. With one sentence, what little hope of respect for this man's knowledge vanished. He said it so dogmatically, so emphatically, with such expertise. Clearly, he doesn't have a clue what he's talking about.

Cardiac pulmonary edema is caused by elevated pulmonary capillary hydrostatic pressure leading to transudation of fluid into the pulmonary interstitium and alveoli. Increased left atrial pressure increases pulmonary venous pressure and pressure in the lung microvasculature, resulting in pulmonary edema.

At some level, if you know you don't know that you don't know, you'll never know.

Amazing

Our current director said yesterday that he believed that "lecturing is one of the most ineffective methods of learning and teaching." And he said it in a manner that was truly engaging.  I think that is current dogma, and the way it's being done here, I would agree. The problem is that is CAN be a very effective method of learning if done properly. And unfortunately that takes, time, preparation, understanding of visual technologies, engagement and talent. I see very little of that here.

A good lecture is focused on the lecturer. The lights are up and the slide show merely augments what the speaker is saying. The primary visual aid should be the lecturer him- or her-self – the effective lecturer is a "player" and presenting the "role" of the content. It is a social interaction between the audience and the speaker to engage both in a give and take process so that encoding can take place in the learner's brain.

This unfortunately requires a very deliberate process of preparation on the part of the professor, and a real commitment to the process. It requires they know the subject matter well enough, and are not afraid of engagement with the student. It requires attention to visual aids that enhance and augment what is being said. It requires paying attention to the syllabus, the required text and the state of the art in learning technologies.

When teachers treat teaching in a professional manner (and that doesn't have to translate into dry, humorless or cold hearted) magical things can happen...and do. But when they treat it as a retirement gig in the Caribe, its laborious for them, and for the students...and very little learning takes place. Those who know, teach...

Why is it that as you move up the ladder from preschool to graduate school that teaching skills and professional approach to teaching seem to decrease exponentially?

Doctorates for Allied Health

Is the clinical doctorate appropriate to the profession as an entry-level degree, as a postgraduate degree, or not at all? That question has been floating around for a long, long time in the allied health professions.  For many professions like physical therapy, nursing, audiology, and pharmacy, the answer is "doctorate, YES", but variable as to where that level should be attained (i.e. entry level vs. graduate degree after entry-level has been practiced.  There have been all sorts of claims, but clearly being called "doctor" has proven valuable to educational institutions who gladly accept huge tuition to get there.

But clearly there will be confusion on the part of the public. A patient off the street not accustomed to this discussion will see the "doctor" as a physician unless very specifically isolated from the generic experience. For those professionals that practice mostly in separate venues this is rarely an issue (pharmacy, audiology, physical therapy), but place a "doctor" where customarily a MD or DO physician is found, and there is likely to be confusion and an increased expectation on the provider.

The driving force is clearly education institutions, faculty and administration. Providers like physician assistants and nurse practitioners don't need that added education to be accomplished providers. Other than to increase individual education expenditure and possible debt, and to increase the already confused world of medical care, will the patient be served in this process? Will healthcare for the expected 50 million uninsured be improved? Will access issues be resolved with higher degrees of education demanding more money in salaries and benefits? Likely not. But the train has pulled out of the station, and if history proves right, nothing will change that.

Patients be warned...ask about the credentials of your provider and protect thyself. The doctor you see many not actually be the doctor you expect. Medical training is 8-12 years long after college and includes post graduate medical training in residency for a reason. It's not just a title...it's a different educational experience.

Happy, Happy

To my Mom and Dad, HAPPY 55 years...totally amazing, totally awesome! It shows a level of love, commitment, sacrifice, support....that I can only aspire to have in my life. I don't think I'll ever miss anything more in life than knowing someone cares unconditionally. You've defined it.

To my sis in law, HAPPY Birthday...Hope is was a wonderful day for you! Thanks for your support and love these past years.

Sorry I missed the bash. When the limo pulled up I thought he had the wrong house and sent him on. Ooops!

Who the...?

Ok, who IS this guy? He has been coming to our class now for several of the last sessions. He's not a student and he sticks out like an endospore on a malachite green positive stain.

I'm pretty sure he is  new faculty, likely taking over the class in which he sits. But we've not been formally introduced. I know I'm a bit of a off the cuff sorta guy, but my Mama and Pop taught me well...when someone is new to the room, you introduce him or her to the folks you are with. I know the instructor knows who he is 'cause I've seen them talking. So, why not introduce him to the group? It's rude, it's downright obnoxious. Worse, he came over to our small group discussion and looked over my shoulder at my computer (the last inner sanctum I actually control) and picked up the book I was reading (A BRS review book on the subject). Ugh!! God knows what kind of gram negatives, salmonella or clostridia are riding bareback on his hands. I'm going to disinfect, sterilize, and autoclave (121 deg centigrade) the book when I get home today.

This place is unbelievable. Schools in general are unbelievable. We've been bitching about the communication for months. Treat students with honesty, and respect and the results are amazing. Treat students continually in a manner that has them defensive, and imposed upon, and you get...this! It's so simple..don't you get that? " Good morning everyone. You'll notice a new face in class today who is going to be walking around and listening to class. Everyone, I'd like you to meet Dr. So and So; And by the way, his hands are not infected with various and sundry microorganisms so allow him to fondle your books at will."

I am continually amazed at how academia works, or doesn't.  The halls of ivy, kudzu, or (in my case) palm fronds, is filled with people playing elaborate parts and no clue at what human interaction is when dealing with students.  I think there is a cultural thing to about students as lowly waifs, worth no more than a string of blue beads.  Why is it that the most simple tasks become so complicated in academia? Like my prof uncle told me when I began teaching..."I hope you know what you are doing, because they haven't a clue about what they are doing." He was so, so right.

Big Shots

"Big shots are only little shots who keep shooting." - Christopher Morley

A Bit Microbe Oriented

It is a real possibility that we may all die directly or indirectly from infection.  There was a family on the island that got very, very sick on year. It was likely food poisoning of an extreme nature like Salmonella. They are buried together in the cemetery here. Sad, but true. Many islanders died of infectious disease and the cemetery yards are filled with that memory. I had the chance to tour some of those sites recently. It is a reminder of how disease spreads, mutates, and kills.

Exams are here for the first round. Nothing unusual about it except nobody knows what to expect from the new profs. Those profs that have been here for awhile have a reputation and there is some sense of what they are about, and what they are after from us. The is the most anxiety provoking part of school for many...what do you want from me in order for me to be successful. That is the purpose of cogent lectures, syllabus, and information provided from the instructor. It is that link between the student and the content that the instructor permits. Remove the instructor, and you have self teaching and guess about the success path. I've learned not to expect too much from anyone and do what I can to just "get er done."

I'm gliding into the rhythm that is island life, and school. I have become more cognizant that it doesn't matter how much you complain or anguish over stuff...there is no way it will improve as long as there is no cognition of the real problems. But that's ok; We'll get what we need and the problem isn't here...it's medical education in general. I've said plenty on that subject.

On another note, it's starting to feel like spring already. The days are getting longer and hotter. The "muggy" is coming back. The water will be warming up slowly between now and summer and I hope to take advantage of that between brain feeds. I'm moving steadily toward being 1/2 way done here, and that feels amazing.  It'll be summer way to soon, and very hot. We need some really strong, steady rain to fill the cisterns before then and before the endospores and bacillus grow rampant.

The only unresolved issue is if I'll actually get Salmonella or not...I ate a product that has been recalled for possible contamination by the recent peanut butter paste Salmonella scare. I'm not sure that I would recognize Salmonella GI symptoms from island food symptoms though. Maybe it'll make me feel better? It is fitting thought that I have this possibility in my life as I study about the medical manifestations of the disease. Perhaps this is just all part of the lab exercise?

Exams-A-Coming

They are looming...2 weeks until first exams. But at 15% they are low risk, and really a time to feel out new instructors with no institutional track record to tap into. The content is voluminous this term, but we have hope that most of it is pretty straight forward, albeit those same pancakes we keep on eating.... 5 a day... everyday... and you have to eat each and every one of them. I know why people get sick of pancakes, but we can regurgitate them all back in about 2 weeks. Some relief in that.

Better? Stop the pancake madness and change to something else...French toast maybe? Like to make me just as sick, but a little more protein. Hope my lysosomal storage mechanisms are working properly.

Topistically Speaking

"Topistics (Dr. E. V Walter)-- a holistic way of grasping a place as the location of shapes, powers, feelings, and meanings..." Mostly feelings and meanings.

Putting that inherently Buddhist nature aside (attached to nothing, with no future, and no past), home is where the heart and memory resides. Where does your heart reside? It could be in the bedroom of your parents home, or in an old house that you toiled to make a home. It might be a deck you sanded and painted, a classroom, a shopping mall you hung at or a vineyard you vacationed in. It could be a storage unit, a girlfriends house, or the back seat of a car. For some, it's multiple locations, brought to the surface by events, or times, or reflections. It is a feeling that few speak for fear of vulnerability, loss or attachments revealed.

But does the place provide the meaning, or does the meaning become assigned by the mind to the place? Dr. Walter attributed those feelings to the "place" and what that place does to us. That seems more like a diagnosis than a sociological phenomenon. It seems to be more a definition and feeling that we assign in our mind to a place. 

Memoryistics (2009): As I shed more places in my life, the "powers, feelings, and meanings" become redefined and scattered once again. I won't let home be where the stuff is or was. Home is where the heart is, and that can topistically be a dream, a goal, a lifestyle and a belief system. For the mind is a place where the heart really is. And memories are dangerous "places" with power, meaning and feelings. Places, of themselves, are not filled with such power. Amazing we do that to ourselves.

"The real voyage of discovery consists not in seeing new landscapes but in having new eyes."  -Marcel Proust

Teaching Gaff

One goal of teaching is connecting the student, in a meaningful way, to the content. My view of teaching is that of a facilitator and "guide on the side" to excite and instill motivation to seek greater detail, and clarification of presented materials in the content.

It begins with a coherent syllabus that dictates how the class will be conducted and the rules of engagement for success pathways. That should also provide information on where the content for presentation, clarification and testing will come from (the "final authority"). That component is all important in this world of unlimited medical resources.

Worse case scenario...change your syllabus at will, teach with slides copied and pasted from a book we don't have access to and is not indicated in the syllabus, and teach in such a way to make it incoherent. That is my class. Same story, different term. Sad really. Just because you have an advanced degree, doesn't mean you know how to teach. I have to remember that. I've also learned that good teachers don't need advanced degrees. Frankly, I'm not sure that you need teachers to learn medicine. Dr. Stead taught me that. Great teacher.

Fantasy Land

I first saw this vessel when I landed in St. Maarten the the other day. It was sitting off the coastal runway, and even then (before I knew what it was) I took a photo. It's huge, and very conspicuous. Surrounded by the masted sailboat and the private jets just highlighted the obvious nature of it's silhouette.

I've never actually owned a boat, but I've had access to them for a long, long time. I've been around and seen big boats forever growing up in Miami and Ft. Lauderdale, going to all the boat shows and recently cruising the Inter-coastal professionally (didn't own, but used the heck out of a few).  But this is a MEGA! And they visited Statia too. What a beautiful craft!

The P*e*l*o*r*u*s is one of the largest private yachts in the world. It is 377 feet long (a football field, plus) and is owned by a Russian billionaire.  It's a big boat. It has a crew of about 45 persons. Amazing by any standard. Seeing it off the coast from my study hall window to the Caribe world was captivating.

I wonder if they need an on board doc when I'm done. Can't be too hard to add a 46 crew.

New Everyday

The sunset is different every day. You think that the sun does the same thing. And in general it does. And in the Caribe, it moves very little thru the year and sets almost in the same place each day. But what's different each day is it's surroundings during that time...air quality, pollution, clouds etc. I guess that's why I'm so amazed at the event each day. It is totally unpredictable, and a moment to just sit, and take it in...as it is...without any imposition from us. This one the other day was so unusual....amazing. Nice to know that I'm still amazed by sunsets. I hope I never lose that.

Hippocratic Oath

Interesting diversion from studies....what do we stand for? What is our history, our legacy, our charge? Is it just a hazy image of a man and his passion for the "art" and practice of medicine, or something more gripping, higher in "the realm"? Is it any wonder that some physicians are not enjoying life, their practice and are so disrespected?  Is the dream possible, practical, and prudent?

"I swear by Apollo, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath.  To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.
I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.  I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.
But I will preserve the purity of my life and my arts.
I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.
In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.  All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.  If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."