Medical Education: Toy Airplane or Stone Flywheel?

Jack Nicklaus, during his first full year as a professional golfer, defeated the heavily favored Arnold Palmer to win the 1962 US Open, launching one of the greatest careers in professional sports.  Would it surprise you to learn that following this achievement, Nicklaus was quoted as saying, “I have golf all figured out now.  Now that I have mastered the game, I should be competitive for the next several decades”?  It should surprise you, because it is not true.  On the contrary, Nicklaus returned to his long-time teacher Jack Grout at the beginning of each golf season to revisit his fundamentals.  It may be apocryphal, but it is widely repeated that Nicklaus would approach Grout every year and reintroduce himself — “I’m Jack Nicklaus, and I want to learn how to play golf”.

This commitment to life-long learning, and humility to acknowledge room for personal improvement, was obviously part of the key to his success.  This commitment is important even in a game which has not fundamentally changed since the rules were established 250 years ago.

Unlike golf, medical knowledge changes rapidly.  In 1950, the doubling time for medical knowledge was 50 years.  When a doctor entered practice, he (in that era, usually “he”) could be fairly comfortable the knowledge and skills acquired were durable.  By 2020, medical knowledge doubling time is projected to be 73 days.  Medical knowledge should now come stamped with a “best if used by” date — it is a perishable commodity.

This dramatic change in the shelf life of knowledge demands a new educational paradigm.  By way of analogy, we need to transition from a balsa wood airplane, to a stone flywheel.

Remember the rubber band-powered, red-propellered balsa wood airplanes many of us had as kids?  You would wind the propeller and watch the rubber band start to twist, storing potential energy.  Wound a little bit tighter, the band would start to double back on itself.  Fully wound, with the flaps adjusted appropriately, launched at the correct angle, it would fly clear across the front yard.  That is much how the traditional model of medical education functions.  Bright young people enter medical school, to have their brains filled with knowledge.  Their red propeller is turned, their rubber band is wound.  On to residency, to acquire an even more specialized knowledge base and skill set.  Wind the rubber band some more, and it starts to double back on itself.  Complete the required training, take the required certification exam, and the rubber band is fully wound.  The cognitive balsa plane is now ready to be launched, hopefully with sufficient knowledge stored to carry a physician through a career spanning multiple decades. 

A better modern analogy is to think of medical education as a massive stone flywheel— heavy, with substantial inertia when stopped. It can take many full grown men, literally shoulder to the grindstone, to start it turning slowly.  Students enter medical school with their flywheels at almost a full stop.  It takes a lot of energy, and a lot of pushing to get the wheel turning. Then something magical happens.  Inertia is gradually replaced by momentum.  As the wheel begins to turn, it becomes easier to push and to get it to turn faster. It spins more rapidly as you complete medical school.  On to residency, where it gains even more momentum.

Finally, off to practice, with a fully and rapidly spinning cognitive wheel, that must continue to spin for decades.  Fortunately, it does not take much to keep it going.  A gentle tap or nudge, regularly and consistently applied will keep it spinning.  However, if the gentle taps are neglected or postponed the wheel will start to slow — even come again to a full stop — and require excessive energy to get it restarted.

The flywheel represents the concept of life-long learning.  Life-long learning is not a program, but a core personal commitment.  It is not Continuing Medical Education (CME) or Maintenance of Certification (MOC).  If I jog three times a week, it does not make me an athlete.  To become an athlete requires more than commitment to intermittent exercise.  It requires a thoughtful and directed training regimen, good coaching, a healthy diet, adequate rest, etc.  Completing a required number of hours of CME does not, in and of itself, keep the flywheel turning.  It requires a professional commitment to continually question your practice, measure and improve quality and learn from patients and other members of the health care team.  It is not a program, but a component of professionalism.  This is perhaps the greatest fundamental challenge of medical education today — to create self-directed and motivated life-long learners.  In other words, to trade in our cognitive balsa planes for flywheels.

Learning Brainstem Anatomy: A Mnemonic Device

For those of you with an interest in neuroanatomy, the attached article presents three simple rules to remember the location of all the cranial nerve nuclei and major tracts.

Access is free, but time-limited (12.11.2014). Anyone who clicks on the following link will be directed to the complete article on ScienceDirect, free of charge. No sign up or registration is needed - just click and read!

Link: Learning Brainstem Anatomy: A Mnemonic Device (free full text)


If the link is expired, here is the reference:

McDeavitt JT, King K, McDeavitt KR: Learning Brainstem Anatomy: A Simple Mnemonic Device”. PM&R 6: pp. 963-966, 2014

Book Review...The End of Absence: Reclaiming What We've Lost in a World of Constant Connection

When I was 16 years old, I have a vivid memory of a thunderstorm.  It was probably a Saturday or Sunday afternoon.  The storm clouds started to roll in, and the thunder rumbled in the distance.  I was outside, climbed on top of an old school bus and lied on my back.  From that vantage point, all I could see was the gathering and darkening storm clouds framed by the leaves of old tulip poplar trees.  I remember the leaves revealing their lighter side in the wind, and the tactile sensation as the thunder crept progressively closer, until the rumble became more of a visceral sensation than a sound.

I do not know why I retained this memory, and lost so many others.  I also do not know if this experience was formative in some way.  Did it alter the way I saw and appreciated nature?  Did it awaken some latent creative impulse?  Did it help to form my metaphysical view of the universe?  Honestly, probably not.  But it was significant enough that my brain saw fit to establish synapses to encode this memory, and allow me to retrieve it decades later.  Furthermore, there is one thing of which I am fairly certain.  Were I sixteen years old today, and a similar storm rolled through town, instead of being caught up in the wonder of the moment I would more likely be texting my friends, playing Halo on my X-Box 360 or interacting with a social media site.

This is the fundamental premise of Michael Harris' The End of Absence: Reclaiming What We've Lost in a World of Constant Connections.  That is, we now live in a fundamentally different world of constant electronic connectivity, and like most transformational societal change, the transition brings great benefit, but at some cost.  This book addresses this important issue through a well defined truism, an underdeveloped hypothesis and an interesting observation.

First, the truism.  The rapid integration of information and communication technologies into our lives has occurred at a stunning pace.  The world has changed, and if you had any doubt of this fact, Mr. Harris’ book does an admirable job of chronicling the sweeping nature of the change.  The first few chapters are chock full of great factoids to fuel your cocktail party banter.  In 2012, the world performed one trillion Google searches in 146 languages.  During that same year we sent each other 144 billion emails every day.  It took 38 years for the new technology of radio to garner 50 million adopters.  Television: 13 years.  Twitter: 3 years.  Google + : 88 days.  The ubiquitous onslaught of communication technologies into our daily lives is consuming time that used to be spent doing something else.  In Mr. Harris’ view, that something else is unstructured time, free of distraction.  His case is compelling, and presented in a clear and concise fashion.  Still, what he has done is document a truism, albeit in a compelling and entertaining manner.  I doubt there is any adult in the developed world today who would disagree with his premise.

Second, an underdeveloped hypothesis.  The unstructured time we have lost is important, as we form cognitive associations in our brains during times free of distraction.  Ideas tend to come to us in the shower. There is an element of serendipity to discovery.  The story of Sir Isaac Newton and the apple is not a myth, but is actually fairly well corroborated.  He was sitting in a garden and was struck by a falling apple.  He had the sudden inspiration that all objects fall directly towards the center of the earth.   Had Newton been working on his iPad, Googling current theories of attraction and crowdsourcing his thoughts across his social networks, would he have still made the cognitive leaps to the theory of gravity and differential calculus?  The fact is, we do not know.  Maybe the intuitive creative connection of his brain would have never made the needed association to look at the world differently.  Maybe he would have gotten there more quickly (his theory was not published for another 20 years).   Harris does a good job documenting a list of dangers from our hyper-connected state; however, the book leaves underdeveloped the evidence that the loss of our unstructured time is having actual negative consequences.  We are evolving cognitively into beings that do not remember actual knowledge.  We remember paths to access actual knowledge.  For example, I know I can Google "Prologue Canterbury Tales" and immediately access the text in the original Middle English.  I can also recite the first 10 lines from memory (Whan that Aprille with his shoures soote…) because I was required to memorize the prologue by my 10th grade English teacher.  Was that act of memorization important to my neuro-cognitive development? Was a moment of quiet contemplation of nature on top of a school bus somehow formative?  I think they were somehow important.  Intuitively, I agree with Harris’ premise, and I wanted to be convinced.  However, I am not sure the objective case was adequately made that we have lost something critical in moments of absence.  The transition from a horse-driven to auto-driven economy and culture brought with it bane and boon.  Few of us would choose to go back.

Finally, the interesting observation.  The concept of “digital natives” (those born into the digital technology culture) and “digital immigrants” (older people who have adopted technologies) is well plowed ground.  Harris proposes we have a micro-generation of people born in the in the mid-1980’s.  This is a generation that were children prior to the information revolution, and experienced unstructured and uncluttered time, but were subsequently raised as part of the revolution.  He postulates this is the only group who can really have any sense of loss in this transition.  The “loss of absence” will be imperceptible to those born in the 1990s and beyond.  

Harris clearly believes (and I agree) “…the brightest moments of human discovery are those unplanned and random instants when you thumb through a strange book in a foreign library or talk auto maintenance with a neuroanatomist.  We need our searches to include cross-wiring and dumb accidents, too, not just algorithmic surety”.  In the world of The End of Absence we will need to find a way to manufacture moments of isolation and serendipity.

Is prescribed exercise in older people beneficial? The answer: a resounding "maybe"

As Medicine continues its journey to become more “evidence-based” it is humbling to realize how little we really know about prescribed treatments.  A case in point:  Is it good to exercise?  In both health and disease?  As we age?  Dr. Marco Pahor and his colleagues contributed one more brick in the wall of evidence in a recent research paper in JAMA.  The short answer -- probably. 

 

Their paper (Effect of Structured Physical Activity on Prevention of Major Mobility Disability in Older Adults, JAMA 2014;311,(23):2387-2396) attempts to systematically address a fundamental question: Does exercise help prevent or delay loss of mobility in older adults?  This was a well-designed trial.  The patients represented a good cross section of the population, geographically and ethnically.  They were typical people, like those seen in a primary care physician’s office: average age 79, obese, sedentary with multiple chronic health conditions (e.g. hypertension, diabetes, cancer).  The follow up period was adequate to detect some longer-term impact of the intervention (average 2.6 years).

The intervention was something the average person could reasonably replicate.  Participants walked a total of about 2 ½ hours a week, supplemented by brief sessions of strength training (using ankle weights) and stretching of large muscle groups.  It is a program you could actually envision a motivated patient performing.  A control group was given general health education classes (plus a little light stretching).  Over 1600 patients were randomized to the two groups.

The primary outcome measure was simple.  All the participants could walk 400 meters (about ¼ mile) upon entry to the study.  Did they maintain or lose that ability during the course of the project?

Results?  At the end of the study period, 30.1% of the exercise group lost the ability to walk 400 meters.  People in the control group (education only) lost this ability 35.5% of the time.  The results were statistically significant.  So, the answer to the question is affirmative.  Exercise does help elderly patients maintain mobility.

So do we now have evidence to support widespread prescription of exercise to octogenarians? Nothing in medicine is so simple.  Taking nothing away from an excellent and important study, it answers some questions, but raises others.

The impact or exercise is statistically significant, but is it compelling enough to zealously prescribe exercise? Compliance with exercise is not an easy task, even in the young and healthy.  If you were told: “you have a 35% chance of seeing your mobility decline in the next couple of years, but we can reduce that risk to 30% with a long-term structured exercise program” is that a compelling enough effect to motivate you to strap on your gym shoes?  Taking the data from the study, a physician would need to convince 23 previously sedentary people to begin an exercise regimen, and those 23 would need to be compliant with the program, to prevent one person from losing mobility.

The study also looked at some secondary outcome measures, including the need for hospitalization, and the occurrence of “serious adverse events” like heart attacks, strokes, or death.  The trend for both was negative.  Hospitalizations and adverse events increased in the exercise group, but in neither case did the effect reach the level of statistical significance.   Had these trends been significant, it would have created an interesting conundrum…exercise would be good for maintaining function, but could actually increase health care costs.

In summary, this study adds to a growing literature to prove what many might think is intuitively obvious: exercise has positive health benefits.  Enough to justify, from an evidence based medicine perspective, a major public health investment?  Enough to drive down health care costs? Probably not. 

Enough to convince you, as an individual to stay as active as you can, for as long as you can.  Absolutely.