Wednesday, January 18, 2017

Scientific Revolution and Medical Student Training

Successful Entrepreneurship and Paradigm Shift. Kind of like bread and butter. So it makes sense to hearken back to the creation of the concept before jumping on the overused "Paradigm Shift" bandwagon. Thus I started with a read of:
First off, readers will note that the word paradigm is not in the title and the title uses the rather boring word "Structure." So to start let's look at how "revolutions" [in a scientific sense, not social] occur in a vast oversimplification of this very dense book.
  1. existing paradigm - how we explain things
  2. normal science - the greater process by which we use the paradigm to investigate and explore
  3. puzzle-solving - the acts that normal science engages in
  4. anomaly - the "hmm" moment. Something is not right!
  5. crisis - the "oh no" moment where it's clear that this train won't get us where we want to go
  6. revolution - the battle between old and new and the conflict that ensues as slowly the old (both in terms of concept as well as often in terms of age) gives into the new
  7. new paradigm - the resolution that the old is gone and new paradigm has taken its place
  8. we start again -> with step #2
Although paradigm shift is trendy, it's actually more useful to follow Kuhn's "structure" and see change as a logical mostly slow process rather than some meteorite smashing into the earth, killing off species, and watching new ones take their place.

He focused on physics especially Newton vs. Einstein. I'd prefer to focus on medical education. Historically we could look at the Flexner Report as an clear example. Schools closed and it seemed that most everything changed. More recently we have the conversion from disciplines (anatomy, histology) to systems (cardiac, neurological) or perhaps the rise of PBL - Problem Based Learning and more exploratory learning via standardized patients. And cool anatomy tables have really neat graphics.

I would argue that sadly these don't make it as potential revolutions and haven't really created a new paradigm. What would a revolution look like? Take for example young people staring that their phones rather than actually talking to people (say their parents during dinner). That seems like a revolution. You aren't expected to talk to people directly, you talk to them via a software agent. I know lots of old people who have reluctantly converted to texting and emailing and using technology to connect with young people. That change involved a lot struggle and conflict (anomaly -> crisis) but eventually it was accepted. No, the changes in medical training haven't made the educators equally uncomfortable.

Normal science (of medical education) is teaching us that there is too much to learn now. And that students don't want to memorize. Solving the puzzle of how to train students efficiently is getting more and tricky as we add in the need to treat them like humans, accept their failings, yet ensure they are are competent. 

But I would argue we haven't hit an anomaly stage yet. For that to occur evidence that the system (not the individual) is failing must occur. And when it becomes clear that this is the norm then we will have a crisis which will demand a revolution in student training and new concept of what "medical student education" is - a new paradigm and thus a "shift". Unless the goal is to get people to attend a conference on the changes in medical education, using the term "paradigm shift" for medical education ignores what Kuhn had to say about the topic.

Predicting the future is often foolish but Star Trek did a decent job 50 years ago (and George Orwell 30 odd years, if you look at repressive regimes) so here goes
  1. The standard 4 years, broken up into 2 "pre-clinical", "clinical" and "the 4th year" [while you are waiting to get into residency] is dead. Some folks will need more basic science, others less. Graduation is based on skills demonstration [per #4] not time spent.
  2. Recognition that the human component of medicine is the part that the machines (e.g. Watson) can't do. Picking out the right drug for a set of symptoms and a given history is task designed for big data and deep learning. Why teach it and why learn it?
  3. The end of the "Primary Care" doctor. The movement to specialists, sub specialists and super sub specialists is well on the way. Increased complexity and the rise of machine decision making will eliminate generalists and that aspect of training. Future scope of practice will become more and more limited (as seen now in surgery vs. non-surgery).
  4. Training will be delivered via online learning in the form of exploratory games that simulate medical decision making and intervention, probably in Virtual Reality and with multiple users from multiple disciplines "playing." Yes, the lecture, the lecture hall, standardized patients, written tests, and even PBL will be gone. Perhaps one can do non-patient learning outside the medical school.
Then we have a new paradigm that normal heath education science can explore and use to solve problems ... until the next anomaly shows up that implies ensuing crisis and ... revolution!

3 comments:

  1. Brad,
    Very interesting subject. The idea of "The end of the "Primary Care" doctor" I hope will not happen. For me and many others I who deal with chronic health problems, the primary care doctor is the driver of the bus or the captain of the ship. They are able to see all the issues, recommend tests, procedures, specialists and then follow up to see the ship has docked safely. The specialists are used to dealing with only their area of specialty and often miss the rest of the body and how their suggested treatment, surgery, medicine can impact a patient's life. I look forward to reading more.
    Cece

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    1. Thanks for commenting.

      I am a strong believer in coordinated care. But is that necessarily a physician's role? Assuming the team includes a public health specialist, a pharmacist, and a dietitian do we want physicians coordinating such a large team? Do they have the time? the expertise? Can we really expect that a single person can keep up with explosion in medical knowledge?

      Also how can we meet the needs of the increasing specialized field of medicine with the workforce we have (assuming there is not a similar explosion in the number of physicians?)

      Lastly there is finance. The country has made it clear that it values primary care doctors less than specialists (in $ and perks and prestige). How do we convince future physicians [who are often highly indebted] to go into a field that isn't equally valued? We typically assume that students should have choice. What if the student trend away from specializing in primary care continues?

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