I found this blog entry amusing (http://www.ithinkwell.org/how-much-do-medicine-and-evidence-matter-do-big-numbers-always-have-the-evidence/). I embedded the video but the blog entry is worth reading.
Monthly Archives: March 2013
Systems Give Us What They Are Designed To Give: Work Hour Restriction Outcomes
A colleague of mine (DB) has a great blog (medrants.com). He posted (http://www.medrants.com/archives/7199) an excellent observation that ABIM pass rates are declining since the work hour restrictions have gone into place. I commented back that why would we expect any different because systems give us exactly what they are supposed to give us. In this case less knowledgeable residents.
The proof is in the scores. Why? My theory is that they waste their off time with being off and not studying. When I was a resident in the mid 90s we had no restrictions, no admission caps and only 1 guaranteed day off a month. We stayed at the hospital until late afternoon at least if not early evening routinely. We studied alot during the day in our down time. The satellite library at the hospital was full of us studying (and yes BSing). I saw alot more patients and did alot more to them than this current generation. Interestingly I dont recall mass killings and mayhem at my training hospitals. But for some reason we have accepted a system (work hour restrictions and admission caps) without testing it ahead of time. No drug gets to market this way but for some reason its ok to let doctors get to market this way.
Being a doctor is complex. Clinical reasoning relies on matching the patient’s story to an illness script. You build illness scripts from studying books (print or electronic…doesnt matter) and by patient interactions. You have to see lots of patients to enhance and mature your illness scripts. Therein lies the problem…..less studying and less patients. Wow…how did we ever get these lower passing rates. Its hard to understand (sarcasm detected). Oh well it doesnt matter. I am sure the wonderfully designed quality measures will make it all better.
Vertical Reading Is Not Just For Clinical Reasoning
Recently I got interesting in more formalized teaching of clinical reasoning. I am currently enrolled in a Coursera (coursera.org) course on clinical reasoning. My reason for taking this MOOC is that I wanted to see how others teach this material so that I could improve my teaching. A great revelation I had while reading Judith Bowen’s now classic NEJM article () and which was reenforced in the Coursera course was vertical reading. The way I summarize this is that we recognize diseases best, not by their similarities, but by their differences. With vertical reading you compare 2 or more diseases by filing out a table with epidemiology, pathophysiology, signs, symptoms, testing, etc. Instead of reading about 1 disease at a time and filling in the table horizontally you fill in the table vertically and read about each component of the table for both diseases at the same time.
The reason I bring this topic up is that I am doing journal club next week and I have asked the residents to read 2 articles on seemingly the same topic. There are nuances that make the articles different but if you read them individually and separately you likely wouldn’t pick up on these nuances. Thus, the vertical reading. I gave the residents a table to fill out comparing the 2 articles. They will read them both at the same time comparing the articles on each of the elements of the table;moving vertically down the table. They should be able to detect the nuances of each article. We will see.
ebmteacher 