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.
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