Medical Education

 Perspectives in Medical Education

Davidoff

Copyright The Common Vein 2014

Approach to LearningThe Common Vein – Copyright 2007As a medical student you will be faced with an overwhelming amount of material focused on the seemingly endless detail that helps to define human anatomy, physiology and medicine.  Amidst this array of facts and terms it can be difficult to envision a way in which the complex detail will unite to form a comprehensive understanding of medicine.  It is precisely this challenge that The Common Vein seeks to address, largely through the concept of “units to unity.”  This motto represents the idea that small units combine to form a whole that is bigger and more powerful than the individual component parts.  This is not only true in the way the cells combine to form the tissues and organs, but it is true in the way a knowledge base should be constructed.  It is a concept manifest in the creation of any artistic masterpiece, as Vincent van Gogh, for instance, created intricate works of art through a series of simple brushstrokes and Mozart composed his symphonies note by note.  It is a concept manifest in the way Shakespeare connects and organizes words to create a genius result.  Learning in the field of medicine requires an ability to connect and organize information to enable its prudent application in the practice of medicine.

First Day at Medical School

Let us follow a first-year medical student who is totally ignorant of all things related to medicine.  On the first day of classes he tells his professors, “I know nothing of this field and want to grow into a compassionate, knowledgeable, thoughtful, and wise physician.”

I might take this student aside and start like this: “You have accomplished much to get to where you are, and you have much knowledge in your head.  Your first few years will add to that knowledge. The latter years of medical school you will spend with patients.

On the compassionate side, start straight away. Perform acts of compassion and true care at home and with your friends and colleagues every day.  Try one act a day, and increase these to 4 or 5 per day by the time you start your second year.

On the knowledge side you will require much dedication to books and other resources. You know and understand that aspect, I am sure.

On the thoughtful side, you will require much understanding.  You will be required to have mastery over the knowledge (not necessarily memory of the detail).  Once you have a sense of the principles you will come to greater understanding.  Once you understand deeply you will become thoughtful.

As far as wisdom goes, having observed this rare trait in a handful of professors, it appears that a tremendous amount of compassion, knowledge, understanding and thoughtful application of knowledge to the patient at the bedside are needed to build a path to wisdom.”

Understanding and Integrating Knowledge – The Challenge

In today’s system of medical education graduates are certified only after having passed two board examinations that primarily test the ability to recall detail.  However, there is question amongst modern medical professionals as to whether or not these exams actually test a student’s knowledge.  After all, true understanding entails far more than the rapid recall of detail

A focus on contextual understanding established through basic principles should comprise a large part of the vision of all medical students to come.   In this way, medical educators may establish a foundation upon which each student may construct an increasingly detailed and elaborate understanding of medicine throughout medical school and his/her career.

Once the universality of principle is acknowledged, the lines that distinguish biochemist, molecular biologist, medical student, lay person, doctor and scientist fade and we perceive these professionals as different only with respect to their language and the manner in which they analyze the human body.  We are fortunate to possess tools to transcend help with language, teachers that help with integration, and guided supervised early clinical years that direct the huge and honorable responsibility of the patient care experience.

 Principles – The Beginning of Understanding

We are going to try and build the perfect career. It is always best to start out as simply as possible, understanding the parts that make up the whole.  The foundation of your career must start with principles.  This foundation has to be rock solid and dependable.  It will all seem ridiculously simple at first – but are not all foundations simple?  Take a walk to the basement of any house and observe the simplicity of structure.  Then take a look at the elegant living room filled with intricate detail.  We prefer to live in the latter but depend on the former for stability.

The single and the simplest entity is called a “unit.”   The unit in biology is called a biological unit.    The cell is a biological unit, the organ is a biological unit and people are biological units.  The cells, organs and systems are connected to each other by common environments, cementing substances, networks of vessels, nerves and ligaments.

Biological units may be solid, like the liver, hollow like the stomach or tubular like the gastrointestinal tract.  All biological units perform three basic functions:  they receive, process, and export.  When biological units are working well and are in order we are healthy.   When biological units do not work well we are in disorder and are unhealthy or sick.  When we are sick enough to feel discomfort we seek medical care, and the basis of medical care is diagnosis and treatment.

There are therefore 5 basic, tenets – a pentad of principles that are founding foundation principles in medicine – structure, function, disease, diagnosis and treatment.

This book, the Common Vein, will embark on a journey with you.  While “common” refers to the common tenets that govern biology and medicine, “vein” refers to those links that connect and keep units together and viable and enable the connectivity required to build bigger units.

Data, information, knowledge, and wisdom.

It may be helpful to envision the concept of “units to unity” through an analogy in which the vast array of medical terms, definitions, and labels can be thought of as a random arrangement of words on the floor of a medical library.  Merely possessing this disordered array of terms will not in itself neither lead to knowledge of medicine nor any proficiency in the field.  Rather knowledge must be constructed through the systematic organization of these words.  This may be accomplished by first recognizing that all the words on the floor of the library may be categorized into the five basic principles that govern medical knowledge as outlined above: structure, function, disease, diagnosis, and treatment.  Given this framework, one may begin to create order from chaos.  With the basic components of medical knowledge sorted in this way, one may begin to understand the body, cell by cell and organ by organ, gradually progressing from simple to increasingly complex.   This means that the cell has structure and function, can become diseased, and there are elements in medicine that allow diagnosis and treatment of cellular disease.  Similarly, the organs and systems and even the systems at large, like society itself, are founded in the conceptual principles outlined.

 

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The basis of medicine 

The 5 piece ikon is grounded by the  two limbs of the basic sciences in the form of structure and function, while the body is the world of abnormal structure and function of pathology and disease.  The upper limbs of our medicine person represent a diagnostic limb and a therapeutic limb.  (Image courtesy of Ashley Davidoff M.D.)10354b03

As you progress through the years of lectures and study, you will be provided with data and information through books, journals and lectures.  It is only going to be through personal effort, thought, organization, connections, and application, that you will effectively progress from information to knowledge and then hopefully to wisdom.

 

The Common Vein is a medical educational tool that seeks to guide its readers toward such a functional, deeply rooted knowledge through the reliance upon basic principles.  The following is an example of how the approach to learning outlined herein may accomplish just that.

The teachers propose that “heart” is an important word for this first year student.  Within that word there is a lifetime of study.  Yet, as the professors point out to this student, the learning process must evolve from the word to the definition, to the paragraph, to the book, and then to the vast amount of data and information reported in medical journals.  The progression from the basics to larger, more elaborate concepts is gradual and at this stage the first year student does not have the ability or the need to explore the sum of all knowledge related to the word “heart”.  Rather, he may move from the word to its definition, which will contain the elements of structure, function, disease, diagnosis and treatment, as outlined above.  Such a definition might look like this: “The heart is a fist sized, four chambered structure that lies within the chest. It functions as the pump of the cardiovascular system.  Coronary artery disease and myocardial infarction are common diseases of the heart and are major contributors to morbidity and mortality in the population.  Common cardiac diagnostic tests include electrocardiography, echocardiography and cardiac catheterization.  Both medical and surgical therapies are utilized in the treatment of cardiac ailments.”

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The Inverted Pyramid or the Cone of Advancing Knowledge

Image courtesy of Ashley Davidoff M.D.) 10357b20

Of course this definition merely skims the surface of the extent to which the heart participates in physiological processes, but it provides a foundation upon which the student may build a complete understanding of the organ.  It also serves as an example of the vertical process of learning whereby one may advance up a tree of knowledge from the simple to the complex.  This approach may be followed to explore every organ of the body and is aptly illustrated by both the inverted pyramid and the branched diagram displayed above.

Within this diagram it is also important to realize that each of the five branches (structure, function, etc.) may be further organized into highly specific subcategories, as illustrated in the diagram below.  The left bottom limb corresponding to structure, for instance, divides into cytology, histology, and anatomy while the trunk of the diagram representing disease branch into the analogues of those subcategories: cytopathology, histopathology, and gross pathology.  Finally, the diagnostic arm of the diagram reflects both structural and functional changes that invoke diagnostic imaging, laboratory investigation, and clinical diagnosis.

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Elements in the Limbs of the 5 piece Ikon

10353 tenets principles structure cytology cytopathology histology histopathology anatomy grosspathology imaging lab clinical surgery medicine diagnosis treatment drawing Courtesy Ashley Davidoff MD ikon TCV

 

Each student has a unique learning style. The tools provided for learning should not only include the classical text books, but also other tools such as computer aided mechanisms that might help. It is also imperative that the same information be viewed from multiple perspectives.

 

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Stacking and Integrating

10355b structure function disease diagnosis treatment drawing Courtesy Ashley Davidoff MD ikon TCV

The five principal tenets outlined in the branched diagram are inextricably related to one another, as well.  Structure cannot exist without function, and function requires structure.  The disordering of these two tenets results in disease and our diagnostic and therapeutic approaches are laden with the responsibility of identifying and rectifying aberrant structure and function.

Integrating basic principles – example a change in size

The basis of biology resides in the cell, and what occurs at the cellular and root level will be reflected in the higher levels of an organism’s function.  For example, as you will review in the principles of structure in the next few modules, size is a recurring theme in both biological and non-biological structures. Furthermore, it is made manifest at every level of the body’s organization.  For instance, if there is disorder in a liver cell that leads to swelling of both the cell and the liver the implications of the size change will be observed at the histologic level and at the organ level. Any abnormality in the liver’s function may be detected through diagnostic tests, whose results typically indicate which course of treatment is appropriate.  Ultimately, progress in overcoming the disease and the success of the treatment plan is gauged according to changes in the size of the affected organ, as evidenced by the results of clinical or imaging techniques. The role of size in each of the five basic principles of medical study is indicated through Figure 3 above, in which size is represented by the red peg.

Differences in Individuals

We all have different learning styles. We study at different speeds, certain detail is interesting and within our comprehension and we have the energy and interest to grapple with the complexity in an area we feel comfortable.  Other disciplines are difficult. They are a grind to study, and the detail and depth simply eludes our capabilities.    For some, the structural sciences make intuitive sense, while for others the functional sciences are preferred.  For some a picture speaks a thousand words and for others a picture is not capable of communicating subtleties and intricacies.  For some “hands on” is the most effective way of study, but for others the book is the source of all knowledge.  Each medical school develops a curriculum that that they feel most suits the needs of their students.  Since all students are unique and have unique styles of learning it is often up to the individual student to modify the process and seek methods of learning that suit them.

Differences in Medical Schools – Curricula and Styles of Learning

 

Curriculum development is complex due to the nature of the issues discussed regarding the integration of the basic sciences with the clinical sciences.  Some schools develop curricula dominated by the vertical learning approach, some dominantly use the horizontal approach to learning, and others employ to variable extent the case based approach, each and all of which have value. Most seem to be integrating the horizontal or vertical approach with case based learning.

Horizontal learning and teaching infers that each of the disciplines is taught in their entirety, crossing all the organs and body systems individually.  Thus one would study anatomy of the body, physiology of the body, biochemistry and histology for example, and this would be followed by pathophysiology and diseases in the preclinical years.  The clinical years would focus on diagnosis and treatment.

Vertical learning and teaching implies that one takes an organ or body system and learns all about its structure function disease processes and then to introduce the diagnostic and therapeutic implications.

Case based approach is the study of medicine by presenting a clinical problem as the starting point to learning, and then through clinical mentors, help guide the student through the relevant and integrated structural functional, pathophysiological diagnostic and therapeutic aspects of the problem.

At some time in every curriculum there is a given primary focus, like anatomy, physiology or pathology, and the secondary disciplines at that time may be clinical medicine.

When the primary focus in the curriculum is anatomy of the heart for example and the secondary focus is the application of this knowledge to clinical medicine, learning the anatomy of the heart must take precedence.  When the dedicated section of diseases of the heart in the pathology course is reached the primary focus is pathology of the heart and the secondary focus is the anatomy, physiology, and clinical aspects.  The point is that it seems prudent to take one step at a time dedicated to mastering one discipline, but always trying to understand its relevance in the other “secondary” disciplines.  In this way a single structure like the heart requires to be studied and learned from multiple perspectives.  There is no single source that allows one to do this.  The vision of the Common Vein is to outline fundamental principles in a web based database, and then to systematically apply these principles to all the organs of the body in a single electronic source.  As detail is added to the principles a consistent pattern for each organ is developed and bricks of manipuable information are created. This will enable the study of the primary discipline but also allows the student to identify its  relevance in the secondary disciplines since in the digital format the information is easily manipulated.

The Same Information from Different Angles – Developing Perspective Depth

The power of CT scanning arises from interrogation of the body from multiple angles.  A single pixel of structure is evaluated repeatedly as X-rays pass through the pixel from multiple perspectives.  The information accrued through this procedure is compounded, enabling one to construct a thorough and accurate depiction of the pixel’s properties.  This interrogation is repeated for every pixel in the body and the end result reflects the true structure of the body as accurately as possible.

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From Pixel to the Elastic of the UnderwearExploring the structure from multiple angles refelects the true properties – Model for learning and education

When the patient is placed in the gantry (blue ring) – during a CT scan,  multiple small X Ray beams interrogate, and gather information about  how each and all of the many pixels that make up the body in the scanner react to the X-ray beam. (b).  This information is sent to a computer which reconstructs the information of the small parts into a conglomerate transverse slice of the body.(c)  The process is repeated at multiple levels as the patient moves through the gantry.  Once all the information of a given part of the body is acquired (in this case the abdomen) the knowledge of each pixel is so exquisite that the information can be reorganized in many diffrent ways to provide a deeper knowledge.  For example the abdomen can be reconstructed in the coronal plane (d) sagittal plane (e), or superficial renderings of the skin and clothing (f,g).  The multiangular approach of looking at the same structure, provides a powerful tool in imaging the body.  A similar multiangular approach at looking at information in order to build a deep perspective and knowledge is recommended to all students approaching a knowledge base.71194c01c02.800 approach to learning CT scan pixel interrogation X-ray detector multiplicity principles Cushings disease underpants coronal sagittal axial transverse 3D volume rendering CTscan learning multifaceted understanding manipulation reconstruction Davidoff MD

 

This multiperspective technique is so powerful because it allows us to approach the true macroscopic nature of structure.  In the case described above we can actually visualize the elastic band of the patients underwear.

Nietzsche’s teachings on reaching the truth through perspectivism are manifest through philosophical pathways, but the essence and the method is the same as the techniques of CT scan and the method of learning that has been promoted above

Theoretically therefore to master a subject one must study it from as many perspectives as possible. Medical school curricula define a direction by designing the curriculum, and recognize that the variety of perspectives have to be included, but by the nature of the science and art of medicine it is a difficult issue.  It is therefore left to the medical student and designers of electronic education to create tools that will allow the student to accomplish this.  This is the challenge of software and content design of the future.

The computer is used extensively in education but its utility to solve some of the issues of individual learning styles, how we learn, is yet to come.  The example of the power of the CT scan rests in its ability to divide the complex parts of the body into discrete well defined units, about which it has discrete knowledge, and as a result it gives us the power to manipulate these units into any form desired.

If we could follow this example and build a tree of knowledge with discrete units of information, then we would be able to manipulate this information into any perspective that suited us.  It could be vertical or horizontal, problem oriented or case oriented.  We have just to solve the problem of how we create discrete units of information.

The Common Vein explores the use and importance of universal principles as the starting units of information.

In – Line Access  (“Point of Care” in the Medical World)

In line access refers to the ability to explore a knowledge base in depth and breadth during a single given session of learning.  When a student takes on the responsibility to look after a patient the most efficient “in-line” access is the students own brain, and in the real world the brain is “it” at the time of seeing the patient.  Prior to the computer age “in line” access was provided by the library at best, and if the student had a personal library the “in line” access was his or her personal learning room. The computer has started to become the “in-line” access of choice because of its evolving depth of resources and relatively efficient and timely access .  It is however far from an optimally efficient resource because of a lack of organization , connectivity and linking of high quality and dependable information.  Time and the evolving culture will advance this aspect of gathering and linking information and making the “in-line” access more efficient and valuable.  The Common Vein is cognizant of the importance of this concept.

Images

Images conceptually speak a thousand words and are able to serve as a powerful tool in education.   The liberal use of images in books has  been prohibitive because of the cost and limited space.  The advent of the electronic format, has allowed liberal and extensive use of images.  Images in combination with text will of course speak more than the requisite thousand words.  In TCV we have a growing library of close to 14,000 images (2009).  The images are integrated in the text as well as being accessible in the “on line – in line” library.]

 

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