In his 1988 book “All I Really Need to Know I Learned in Kindergarten”, Robert Fulghum takes a tongue-in-cheek approach to education. His intuitively attractive postulate is that early learning is the most durable we will experience, and those fundamental lessons and principles, well established early in life, can be the most valuable contributors to lifelong learning.
I found myself thinking about this recently after reading a “state-of-the-art” article in the Journal of the American College of Cardiology entitled “Pathogenesis of Acute Coronary Syndromes” (Crea F, Liuzzo G, JACC 2013;61:1-11). The authors provide a contemporary review of the pathophysiologic underpinnings of ACS, describing a complex interplay of structural, inflammatory, metabolic, hematologic and genetic factors that can be at play and can lead to the various clinical presentations we recognize.
Over the years that I’ve been in practice, the understanding of what causes ACS has evolved in a steady and very gratifying manner. In medical school, the concept of myocardial ischemia my classmates and I engaged was encapsulated by a famous Frank Netter drawing of a businessman with a briefcase clutching his chest leaving a restaurant (presumably having enjoyed a large meal) on a cold day. In retrospect, it’s easy to dismiss that image as a rather quaint and simplistic model of what turns out to be a rather complex process.
However, when I think about the fundamental science that underlies the current mechanisms developed in Crea and Liuzzo’s article, I realize how many of those key concepts were first, and very accurately, developed within basic science courses we undertook in our first year. Concepts such as:
• the structure and histology of coronary arteries
• the inflammatory response
• platelet aggregation and thrombosis
• arterial vasospasm
• genetic predisposition to disease
• lipid metabolism
• sympathetic responses to exertion and emotional stress
These topics, esoteric in isolation, have a few, very interesting things in common.
• They are all necessary to understanding current concepts of ACS
• Knowing something about them allows me to appreciate (and even enjoy reading about) contemporary approaches as outlined in the JACC article.
• They were all part of my medical school experience 35 years ago
While I was struggling to learn those concepts, I had no idea they would ever have practical impact on my practice. In fact, my classmates and I were of the very strong opinion that learning these concepts was a decided waste of time that could be better spent seeing patients and learning the “nuts and bolts” of clinical medicine.
Today, undergraduate curriculum committees, including ours, continually struggle with the questions “what should we be teaching” and “what will they need to know”. The desire to ensure the scientific foundations are appropriately presented has to be balanced against current trends to provide more “patient-centred” content, to provide “clinically relevant” content, to ensure our students are introduced to the ever-expanding compendium of clinical knowledge and therapeutics.
But are these forces really at odds? Do we really need to choose between what’s “science” and “clinical”? We don’t, as long as we’re willing to consider new approaches to education. The answer to this apparent dilemma lies in development of integrated learning that doesn’t segregate and marginalize the “science”, but brings it front and centre, linked appropriately and logically to the clinical contexts in which they’re utilized.
Within the next few weeks and months, Dr. Michelle Gibson, Year 1 Director, and Dr. Chris Ward, Course Director for Normal Human Function, are leading a comprehensive review of our objectives in Basic Science. It’s become clear after five years of application that the current framework outlined in our “red book” (Curricular Goals and Competency-based Objectives) merits review and likely revision. In doing so, they will be engaging the faculty at large and will welcome your contributions.
So, do I believe I learned everything I really needed to know in medical school? No. But I certainly didn’t appreciate at the time how useful that learning would prove to be.
Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education
I don’t feel I can comment on Queen’s UGME Basic Science curriculum specifically as I haven’t experienced it first hand. However, I continually feel that had I had more basic science than I did, learning clinical aspects of disease would be easier. It would allow me to understand drug mechanisms more fully. Remembering manifestations of disease would be easier if I knew more of the pathogenesis. These are but 2 examples. Ultimately, with a stronger basic science background, I feel I might be more confident in my skills and thinking processes.
However, where I think there is much more of a dearth in medical curriculums across Canada (and probably the world) is in psychology/cognitive science. This area can not only help learners “think about their thinking” to identify patterns that may emerge or lead to errors (either in medical school or more importantly – diagnostic errors with patients in their careers), but can also lead to better patient counselling skills and understanding of the human psyche, which has such a huge impact on disease. For example: telling an overweight patient to join an exercise class or to work out with a buddy to try to increase motivation won’t be of much good if the patient is ashamed of his/her body due to weight discrimination and doesn’t like to be seen exercising in public.
Thanks for the insight and interesting comment. I must admit that we have not included pyschological and congnitive sciences as heavily in standard medical curricula, but you make excellent points that I’m sure will lead to further discussion and thought among our curricular leads.
Dr. Sanfillipo,
Very interesting perspective. I am looking forward to seeing what it is years down the road that I am not fully appreciating about my education now.
Danica and I are admittedly cross country collaborators in the online medical education world. These are some of my related thoughts in a recent blog post. It suggests simple ways that we could use Facilitated Small Group Learning time to explore some of the cognitive science learning that she speaks of.
http://manuetcorde.org/2013/04/08/facilitated-small-group-learning/
Eve Purdy
I think there is another aspect that needs to be considered too, and that is the matter of scientific reasoning and method. The teaching used to give us a sound appreciation of this process, which undoubtedly does last for the rest of our lives, and most certainly applies to clinical reasoning. I can remember still the painstaking descriptions my professor of physiology used to supply of, say, Harvey’s vivisections of the heart and blood vessels, or the trials carried out on poor Alexis St. Martin, after he suffered a gunshot wound which left him with a gastrostomy. These stories demonstrated to us how scientists think and work. I get the impression that nowadays, if you introduce this sort of material to class discussion, you run the risk of accusations of teaching ‘in the past’, and indeed I can recall recent occasions when budgetary allowance has been denied to my department for any books that are more than ten years .out of date.
Referring to a botanic subject, I recently mentioned this in an email to a colleague, a neurophysiology professor, as follows:
“Sadly, I still haven’t figured out how the cones develop on the spruce trees. I find them on the ground, but seldom see them on the trees. This led me to conclude that they only form on very large trees and at the tops of the trees, where I can’t see them. I was rather proud of this deduction and thought of it as scientific reasoning. It reminded me of my old textbook of physiology, which I used as a student in the 60s: it was by three gentlemen named Bell, Davidson and Scarborough. In their text were numerous examples of statements which demonstrated scientific reasoning, and I wonder whether modern textbooks, by contrast, simply give the facts, and emphasize that knowledge of facts is what is required, rather than figuring things out. Consider a statement like the following (I still have my copy of the book):
‘If oxalated plasma has an excess of calcium added to it, clotting occurs, showing that calcium is necessary for coagulation. It also shows that clotting occurs in plasma, and that red and white cells are not involved.’
“This sort of statement could be found everywhere in the textbook, and often the student was left to draw his or her own conclusions, ie they were not drawn by the authors (as in the above example). As I say, I wondered if this style of writing had disappeared from modern day textbooks of physiology. Anyway, I intend to investigate this further in the near future.”
I know he won’t mind me quoting his reply:
“Explanations of why we believe something have disappeared from textbooks of all kinds. When I taught chemistry, I didn’t even teach that atoms were real. There is nothing in a introductory course that demonstrates
their existence or cannot be understood without them.”
This is an interesting issue you bring up and is one I am concerned about as well. I feel it has a direct connection with clinical reasoning. Picking apart how one deciphers things and parts that do and do not fit in a purely scientific endeavor is very similar to picking apart a patient’s presenting complaints and what parts may and may not fit with the diagnosis one is considering.
Additionally, I feel learning about how/why something is the way it is will surely help me to remember it. To use your example, if I were to forget where exactly in the blood clotting factors were, I could go back to this “story” of the discovery process, and I would surely then remember. I feel humans are designed to understand stories.
As for your concern about being labelled as “teaching in the past”, I understand and can appreciate this. However, it is the same for students who are interested! If one is interested in knowing how or why something works the way it does, s/he risks the wrath of classmates who perhaps aren’t so interested, and the time it may take from the lecture for learning things for the exam. It seems a cultural shift, and those who are still passionately curious run the risk of a small bit of vitriol. Of course, as with all things in life, a good balance is key. Too much of one or the other leads to problems.
Hello Danica,
These are excellent insights and I’m pleased you shared them with other readers. I’ve been getting similar informal feedback from students I’ve talked to. The “deeper learning” you refer to is what newer teaching methods strive to provide, by focusing on the application as well as retention of fundamental information. My generation came upon this through experience. Hopefully we can develop educational methods that will make this a more natural process for current learners.
A depth of knowledge about all the variables (that are known) about a subject is always preferable to a focussed approach which may solve one problem, but does not solve similar, but different problems. An elegant approach, which gives enough background to encompass different manifestations whilst at the same time giving direct and individual attention to the presenting problem.
For example, a comprehensive knowledge of addiction characteristics, together with the ability to personalise the steps necessary for individual recovery, can help deal with such differing behaviours as alcoholism, drug addiction, problem gambling, overspending, sex addiction., etc.
A narrow view approach concentrating on passing an exam is not conducive to working through all the different facets of most presenting cases.
Of course, we all know that cones come from the Cone Fairy, and I am surprised that Adrian did not know that.
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