Chapter 22: Keeping upto date – learning how to learn
|"It is impossible for a man to learn what he thinks he already knows."|
Most doctors take pride in their medical knowledge, and the hallmark of a medical professional is his medical expertise. Unfortunately it is a sad fact of life that most practicing doctors are too busy to keep up to date with the newest medical knowledge . Few read medical journals ; some do attend medical conferences, but primarily to meet friends and socialize , rather than to learn; and most depend upon their "friendly " medical representative to educate them. Many senior doctors feel that their years of accumulated experience mean that they do not need to learn anything new anymore. However, as Michael O’Donnell points out in A Sceptics Medical Dictionary , clinical experience can be defined as making the same mistakes with increasing confidence over an impressive number of years.
This sorry state of affairs a poor reflection on the medical profession today and can actually be dangerous for you. Thus, if a patient has a poor medical outcome because you are not up to date you can be sued for medical negligence. Keeping up to date is important not only to protect yourself , but is also essential if you wish to build a successful medical practice. Your colleagues are much more likely to refer patients with complex problems to you if you have a reputation for being well informed and well read.
Unfortunately, most doctors have never been taught how to learn. While we have all learnt how to cram, burn the midnight oil and bluff our way in the viva, so that we managed to pass all our exams during our days as medical students and residents, most of us have never learnt how to manage knowledge. We need to remember that we are now adult learners , and have different learning needs , as compared to the days when we were medical students, and our only requirement was to pass an examination.
One of the reasons many doctors find it difficult to continue learning is that they are often not motivated enough, and most carry on a successful practice based on outdated information which they were taught decades ago. Another problem is the sheer size of the information which needs to be mastered. Not only does the task appear overwhelming, the rate of acquisition of new information is so rapid, that keeping up seems to be a full-time job ! As a famous medical professor once told his students, " Half of what I am going to teach you is wrong – and I don’t know which half !” Not only does medical knowledge have a short half life, we are also literally drowning in an information overload.
So how can you cope ? Essential to information mastery is understanding the relationship between data, information, and knowledge: data are raw facts and figures; information is data organized into a meaningful context; and knowledge is organized data (i.e., information) that has been understood and applied. We need to focus on knowledge, and hopefully transmute that into clinical wisdom with the help of experience and judgment.
While it is important to retain the information you need on a day to day basis in your head, it’s even more important to know where to find reliable information when you need it – for example , when you are presented with a patient who has a difficult clinical problem. Unfortunately, even in this day of "information overload” where doctors are surrounded by tons of information , studies show that approximately two–thirds of questions that arise in a clinical practice remain unanswered ! It seems to be a case of : " Water, water everywhere, but not a drop to drink !” This is because doctors need user friendly information, at the "point of use” – at the patient’s bedside , when it can be applied clinically.
Most doctors are reluctant to "look up " information in front of the patient , because they feel that this will cause the patient to lose confidence in them, as it suggests that the doctor does not know everything. However, good doctors have learnt that looking up information in front of the patient can actually impress the patient that you have taken the time and the trouble to confirm key facts – and this can be very reassuring to the patient ! Every doctor needs a personal medical library, so that he has the information he needs at his fingertips. However, medical books become outdated and journal subscriptions are very expensive. Fortunately, the advent of the internet has made accessing knowledge much easier – and much less expensive as well ! MDConsult , a commercial service at https://www.mdconsultindia.com, provides Indian doctors access to the world’s largest online medical library, with over 40 full text respected medical text books and 50 full text medical journals, for less than Rs 6000 per year !
US companies have gone one step further, and now offer ingenious software solutions tailor made for doctors, which provide medical knowledge at the bedside through PDAs ( hand held personal digital assistants, which act as intelligent electronic aides or "peripheral brains”). Even more exciting is the recent use of computer technology to assist doctors in applying their knowledge to solving clinical problems. Computer support can be used to make the best possible medical decisions , and expert systems and artificial intelligence hold a lot of promise. Excellent examples are Medweaver at www.diseaseref.com and PDXMD at www.pdxmd.com.
Doctors are lifelong adult learners , and the key to knowledge management is self-management: knowing what you need to know. You need to be your own filter, so you can turn off unneeded data , and focus only on what you need to know, so that your learning is self-directed. You should also be aware of your preferred learning style. Many doctors learn by reading, while others prefer alternative options:
All the learning in the world is of no use until you integrate it into your clinical practice. An efficient way of doing this is to develop clinical protocols or flow charts for tackling the common problems you face on a daily basis. You can then update and modify these protocols, as you acquire new information. Not only will these protocols allow you to learn more effectively, they will also help you to practice medicine on a more systematic basis.
To become effective learners, we need to make use of insights from the field of adult learning, which teaches that as we mature, our approach to learning changes. In order to learn new information, we require that this information be interactive; relevant; practical; and connected to past experience. This is why most doctors promptly forget over 90% of what they hear in a lecture in a medical conference – because the information is of little practical use to them, or has been poorly presented. This is why newer teaching formats have been developed, which use multimedia and computer simulation, and since these actively involve the learner, they are more effective in ensuring that the information transmitted is retained.
Knowing how to learn is essential, and you need to find out which of the following learning styles works best for you.
Activists believe in doing things, and their philosophy is: "Ill try anything once". They are happy to try out the newest drugs, and thrive on the challenge of new experiences but are bored with implementation and longer term consolidation. They are happy to play with new medical equipment and love devising new instruments and operative techniques.
Reflectors like to stand back to ponder experiences and observe them from many different perspectives. They collect data, and prefer to think about it thoroughly before
coming to any conclusion. Their philosophy is to be cautious, and they prefer sticking to what has worked for them in the past and stood the test of time.
Theorists adapt and integrate observations into complex and logical theories. They think problems through in a vertical, step by step, logical way. They like to analyse and synthesise. They are often the medical college professors, who prefer looking at the "big picture”.
Pragmatists are keen on trying out new ideas and techniques to see if they work in practice. They are down to earth people and their forte is solving problems, which they see ‘as a challenge. Their philosophy is: "If it works its good"; and they are interested in getting results, rather than worrying about why things work the way they do.
Each learning style has its own advantages and disadvantages. It’s helpful to experiment with different styles; and you may also need to adapt your style, depending upon the material you need to learn !
The most effective way to learn is to learn around your patients. This is the secret behind most successful doctors– they use their patients as their textbooks. Patients present with clinical problems, and while most patients have "garden-variety” routine problems which are easy to tackle, some have complex problems for which you need to hunt for information in order to provide a solution. Finding out information about your patient’s problem is the best way to keep on learning. Most of us remember our patients, and if we read about their illness, this knowledge will "stick”. You can find this information formally by referring to text books and journals – or informally, by talking to colleagues, or referring your patient to a consultant. This is why you should treasure your rare patients – because you learn the most from complicated cases !
The best doctors are those who learn the most from their patients – after all, patients are the true experts on their own illness . While they may not teach you about the pathology of their disease, your patients can teach you a lot about courage, coping skills , how to die and even how to live – if only you will listen . As a doctor you are privileged to be granted access to a human being’s innermost secrets - make the most of this privilege !
Your mistakes can be very valuable teaching tools. We all make mistakes in medicine – after all, this is an imperfect science and we are all human beings. However, rather than try to "bury "our mistakes , we should actively try to learn from them. A post-mortem used to be the classic teaching tool in medicine for exactly this reason. Of course, rather than make mistakes, it’s best to learn from others’ mistakes. This is why CPCs ( clinicopathologic conferences) are such a useful learning tool. Unfortunately, most of us hide our mistakes, rather than try to correct them , which means that valuable learning opportunities are lost.
We all have areas of ignorance . Rather than be ashamed of these , we need to actively identify these , and try to fill in the gaps in our knowledge. Remember that nothing is so difficult that it cannot be learnt !
Learn other stuff as well – not just medicine ! The more you use your brain, the better it performs ! Learning is fun if you are motivated – and you can have a ball learning new skills, such as tennis or golf.
Finally, remember that the best way of learning is to teach ! If you do not have medical students, you can always teach your patients . This is not always easy to do – after all, you have to understand a topic very clearly before you can successfully explain it to someone else !