Tuesday, February 23, 2010

Beginning With The End In Mind.

To begin with the end in mind. This really really long massive wall of text is a reflection of what I feel medicine is all about...which in turn will form the basis of my next (long massive wall of text) about my study approach this year. First up, a two questions I get asked all the time...

If you are a medical student or doctor wondering why I am not using more concise terms, please note that alot of effort has gone into ensuring that minimal medical jargon was used. This is written such that a layperson...mom and dad... can easily read it.

Is medicine difficult?
No. It's not. However it is very very difficult to get a high distinction in medicine. What makes it hard to score in medicine is the fact that students are selected from the top 95th percentile of their academic cohort...yeah, the super-nerdy-anal-retentives tend to get in. It's difficult to get in because every next student seems to want to become a doctor, but once you're in, a little perseverance goes a long way. All I did in 2009 was hit the wards about twice a week and attend all the mandatory lectures on Wednesdays. Last year was sort of a flop for me, totally disorganized, yet even with only 30-odd hours put into study before the finals (ask my friends from the halls...it's true!) I somehow passed with an average score slightly above the first quartile. Yes, I was in the bottom half of the cohort, which by asian standards equals fail. So now I have to work to not fail.

Why medicine?
Ask any highschool student who says they aspire to become a doctor. Responses will vary, from the stereotypical "it's my calling" to "i want to help people". It feels good saying things like that. But seriously, nobody in form 5 (Year 11) really knows what they want to do in life. Then why does everybody seem to want to become a doctor? I will be lying to your face if I told you that it's not about money and job security. For at the end of the day that is the reason why medicine is one of the hottest courses at any university (hence the competition to get accepted into the course). Personally, I am very thankful for the opportunity to pursue a career in Medicine. Now in my second clinical year, I am starting to really appreciate the other reasons (oh you know...the ones that you say in your medschool interview) that make Medicine so exciting and rewarding. Any high school student can say "oh it is rewarding" but that would be like a five year old saying "romance is exciting". I am in my fourth year of being a medical student and I am only now discovering how deeply rewarding medicine could be.

Medicine is interesting. It's a nice mix of knowledge and art (below), and it is up to an individual medical student to develop his/her framework of clinical reasoning.

The Art Of Medicine
Textbook knowledge is dry, and seriously no doctor knows everything in the textbook. But the thing about clinical practice is that you dont need to know everything in the textbook. In fact, knowing everything in the textbook without clinical perspective is actually a bad thing. Why? Because medicine is at the end of the day an art. It's a combination of pattern recognition and deductive reasoning that gets more accurate with clinical experience and raw background knowledge on a subject. The worlds best pediatricians, with the best tools and technology, only correctly diagnose appendicitis about 90% of the time. It's more like 75% on the general wards. This means that 10% of kids will have the surgery (it's a minor one) and they will find something else, or nothing at all.

Patients dont come in saying "hey doc I've got a C. difficele enterocolitis probably caused by the course of antibiotics I took for this bacterial pharyngitis I had a three weeks ago". A patient will walk in complaining of a tummy ache and loose stools. Only on questioning will he recall having a sore throat some time ago and taking some pills for it. Now a textbook is going to give you a list of 20 conditions that can cause a patient to complain of X and Y. It is up to the clinician to know what is common and follow his instincts to derive a diagnosis by taking a history and examining the patient. Some patients have vague histories, and some clinical signs on patients are not diagnostic at all, but when everything is put together, it all makes sense, and in the end there are only a few possibilities that stand out. 90% of the time, a careful patient history and examination nails the diagnosis spot on. Whatever tests are done after that functions simply to confirm what the doctor already knows. The remaining 10% of the time when a doctor is unsure about what could be going wrong, lab tests (eg. blood tests) or imaging (eg. Xray) are used to get an idea of what is happening to the patient. A clinician will not be able to list out the 20 things that a textbook lists out (he knows about them though), but after examining the patient and asking the right questions, he will know what the problem is. This is why route learning is useless and there is no substitute for experience combined with a deep background knowledge of how the human body works and what goes wrong with it.

Note that it's not just about "following your instincts". A doctor also has to know about red flags associated with patients complaining of X and Y to rule them out. You do not want to falsely reassure a person who knocked his head, seems fine on examination, gets sent home, and goes into a coma later in the day...just because you forgot to ask if he had an episode of nausea and vomiting (a neurological sign) when you interviewed him.

And when a patient comes complaining of X and Y...and a correct diagnosis has been made...a doctor then needs to know what to do, both initially and on the long term. The first thing a patient would want to know is the severity of his condition, so a doctor needs to know what to tell the patient (or the patient's parents) what will happen as the condition progresses/resolves.

Being to do all of the above requires a good deal of knowledge, experience and confidence. Essentially:
1) To know what to ask a patient complaining of X and Y. To know how to examine a patient appropriately to look for signs that would help you figure out what is going wrong.
2) Pattern recognition for making a diagnosis.
3) The ability to detect and rule out red flags that could present the same way as common ailments (eg. A kid with what appears to be a viral fever may actually have infected kidneys).
4) Know how to confirm a diagnosis (what you suspect is going on). And how to judge the severity of a disease.
5) How to treat the patient initially and on the long run.
6) Knowing the disease/condition that the patient has and being able to tell the patient what's going to happen to him. (prognosis. eg. "You have a type of blood disorder called hodgkin's lymphoma and it is very treatable with over 80% of people in your shoes getting cured")
7) Knowing how to keep up to date with the latest developments, and use evidence based medicine to provide the best standard of care to patients. <-- this is what differentiates modern medicine from "traditional" medicine. One has evidence behind it...Even if we dont know how treatment X and Y works, we know from blinded, randomized studies that it does work with certainty. Yeah, there's a bit of epistemology (philosophy) and statistics in medicine as well.

So, from BACKGROUND KNOWLEDGE, a doctor knows what questions to ask you when you complain about X and Y...and knows what to look for when examining you too. The doctor then relies on his EXPERIENCE along with his background knowledge to determine what's going on. A good doctor will ask questions and examine you for signs that RULE OUT UNCOMMON THINGS that could be very bad for you if not detected. The doctor then needs to know how to confirm what he suspects from pattern recognition. Quite often (especially in General Practice) tests are not even necessary for a diagnosis to be made. A 2 year old kid with a seal-like (the animal) barking cough and hoarse breathing almost certainly has Croup - a spot diagnosis before the patient even enters the room. Then comes actually TREATING a patient. In practice this generally requires knowledge on how the body works and what drugs do to it. Practical treatments that involve physical maneuvers also need to be mastered. Nothing looks worse than an ugly stitch...or having to make many attempts to pop a poor guy's dislocated shoulder back into place. The whole process of finding out the cause of people's health problems and fixing them is very very interesting. Think of what House MD on television does... Ok, it's not as dramatic in real life, the interns arent as pretty, and believe it or not, most patients dont have sarcoidosis =P ..you get what im trying to say.

The real difficulty is actually building up the necessary background knowledge and intuition that comes with experience in order to ask the right questions and do the right examinations. Pattern recognition follows naturally and the right conclusion will be made. Treatment is pretty much textbook material and is learnt by route learning and experience. Again, no doctor knows every treatment in the textbook. Experience is used for the common things (eg. asthma, UTI's), and guidelines (yes, doctors cheat by looking up reference manuals too!) are used for the more uncommon ones.

The sheer time, physical effort and mental effort that go into what is highlighted in red above is one of the reasons why a MBBS degree takes five to six years. Even then, one is only a lowly intern...Real experience for about five years is necessary before specializing in a particular field - a process that takes another five to six years. This is why you dont see any young cardiologists or neurologists around.

Now I need to ensure that my study approach is in line with what medicine is all about...So what can be done? What is the best way to approach medicine as a whole?


  1. i was looking for other EZRA's who liked photography. hehe. and i found u.

    nice photos! i just started a photoblog myself.. hope it works. :)

  2. Heys. Nice summary of what you do ;D

    "This is why route learning is useless and there is no substitute for experience combined with a deep background knowledge of how the human body works and what goes wrong with it. "

    I think all streams/fields are the same when you think about it. You have to have deep background knowledge of whatever that you're involved in to be good at it.

    Youtube Peter Schiff if you don't already know about him. Knew the GFC was gonna hit. Why? Thorough understanding of simple economics. He kinda tried to "cure" the patient which was the "US economy" but the patient didn't listen.

    - browsed ur blog because i have nothing to do while eating nong shim for a late night snack lol -