In the first part of this series, we ended with the thought that, despite the legacy of strong thinking in medicine, present-day practice seems somewhat lost. It is probable that this started to happen as the old, mentor-apprentice teaching model gave way to what can best be described as “mass production” of doctors in modern education. Osler was a powerful force in shaping the modern education of doctors and amongst other things created the residencies and internship posts we know today. But Osler also wrote a lot about attitudes and thinking and spoke passionately about the intangibles that were so important. We have records of those talks today and so can be certain that he could see a lot of what is somehow now being lost.
Doctors are people and they have a very finite tool in their skulls.
Vesalius and those after him have described in ever-increasing detail the anatomy of the brain we possess to think with – it is our ultimate medical tool. Beyond anatomy, modern pioneers like Daniel Amen have developed ways to look at how the brain works and not just describe its physical structure. Cognitive psychologists have found ways to make theories to test how the brain works, and other great thinkers, like James Reason, have described models of decision making and, more importantly, models of how we can think poorly or be fooled and ultimately get things wrong.
Mass education of doctors does produce something of a standard, but it isn’t a very high bar. Universities may want to argue and I don’t want to criticize universities, but the fact is that nobody feels safe with a fresh-out-of-med-school graduate. In fact, a graduate can’t get a license to practice until at least one year of practical experience is gained. This is evidence that we know something else has to be learned first. Most of us actually feel better working for three or four years after graduation, under tutelage in an academic teaching hospital, before feeling competent.
So we know, deeply, that a university degree is only a starting point, it does not confer competence.
So what is the missing bit universities can’t or aren’t teaching? It’s this bit in our brains mainly. We call it “experience” which is simply a way to refer to something we don’t understand, something you learn by “doing the job.” What we are learning, or rather creating, are a lot of mental models that we use to recognise scenarios, predict outcomes and match suitable responses. It’s something very definite but often very subconscious unless it is specifically brought to conscious awareness. And it influences the outcome of clinical situations more powerfully than any drug can.
Good thinking results in good plans and good outcomes, poor thinking the opposite.
Medicine, paradoxically, is today facing a great crisis; the great historical poster child of brilliant minds is awash with mediocre and often dangerously mediocre thinking.