How much of medical school and day-to-day medical practice is rote memorization?
TV would have me believe that you can walk up to a doctor and say, “Patient has a headache, diastolic blood pressure 50% above normal, a red, itchy rash on the left thigh, and nausea.”, and get a response of, “Cystic Quadahemic Nargonosis of the Knee of the Left Knee. Elevate the knee, provide 10mg hemipyrite tablets morning and evening and check for glargosis. If glargosis occurs, treat with a 100 mg venex injection each hour until glargosis subsides.”
How much of this is reality? Is this what you have to do in med school? When a doctor treats a patient in real life, how much time do they spend researching (e.g. literature review, or actual experimentation) before making a diagnosis and recommending treatment?
From my anecdotal experience, a large portion of graduating from medical school and passing the requisite exams involves exactly that type of rote memorization.
The questions for medical boards, as the test I am most recently familiar (second-hand) with, are of the exact variety you posted from TV. “Patient presents with X, Y, and Z. History is H. Labs show Q. What is the next treatment?” You must answer this question with no reference material.
In real life, of course, you have more time to analyze the situation - but often these types of diagnoses and prescriptions must be made in real-time (especially in emergent situations). You also have the benefit of other staff if you need a referral.
The thing is, a huge portion of the cases you see will be the same common ailments. You don’t need research to treat your 1000th hypertension patient, or your 2500th diabetic. The more rare illnesses, of course, might require a visit to the literature.
To be honest, there is far less memorization from charts as you might imagine. Much of the memorization in medicine revolves around systems which make sense inherently. If you know 80% of a certain category of information, you can pretty accurately guess what is missing. Most of clinical medicine revolves around common sense, with a few hard points of knowledge thrown into the mix. That is why doctors turn their noses at patients who come up with their own diagnoses. It is often because those diagnoses fly in the face of the common sense that physicians use every day.
I’m in medical school (almost done!), so I can talk pretty confidently about all this.
Large portions of the first two years of medical school were vast amounts of memorization and regurgitation. After that less so. In practice very little. Not much new memorization anyway.
I put it a different way to the students and residents that rotate through our practice site - the first phase of learning diagnostics is recognizing what pattern a set of signs and symptoms fit. The more important phase is learning when it doesn’t fit. What happens is that you pretty quickly get good at recognizing the patterns you actually see with some regularity, making those connections, and going from there. The skill becomes recognizing that this time it is not one of those pattens after all, stepping back, clearing your mental slate of preconceptions, and looking at it fresh, digging for more information as needed. Not knowing what it is yet, but knowing that this time it is not the usual suspect.
The pattern fit part is prehaps pretty rote and honestly in real life clinical life not so big a list. The misfit part is not so rote.
A long time ago I saw a film (Arrowsmith?) in which a med school professor throws (literally) a thick book at a student, asks him to open it to a page at random and tell the professor the page number, whereupon the professor proceeds to recite it. I think the point was that the students were expected to memorize it.
On the other hand, my GP, when stumped, will open a book on the spot and try to glean useful information. I respect him for that.
I’d say that the preclinical years of med school are about 80% memorization and 20% “understanding” of processes and such. Once the clinical years come on it’s probably closer to 50/50.
Once you’re practicing, I’d say it’s about 20% relying on previously memorized knowledge, 70% understanding of processes and systems, and 10% a little alarm in your head that says “I remember something about this combination of symptoms; let me go look it up.”
From observing friends in med school way back when - they went into their room in September and came out in June, and studied all that time… but it seemed as much a matter of “memorizing” systems and processes. Yeah, you had to know the names of the bones and muscles, but also it was things like - “What can cause high blood pressue? Low blood pressure?”
This is a good example, because you can’t jump to conclusions - The person may have low blood pressure for something unrelated to the trauma you are examining them for, in which case if your assumption is wrong, you may apply a totally inappropriate treatment.
So I guess - do you mean “memorize charts and graphs and lists” or “memorize a huge array of details about inter-related systems, cause and effect”?
I dated a girl while she was finishing med school and while she was a resident (also knew her all the way back to undergrad). She was not the sharpest tool in the shed, and tried to always memorize everything. My constant encouragement was to learn rather than memorize - if you understand how the machine works, you can fix it (or at least identify the problem).
She successfully passed the boards (barely, and on her second try). But I think that her real handicap was an inability or unwillingness to step back and look at the subject as a whole.
Don’t get me started on trying to get her to understand molecular chemistry from a molecular standpoint (balance the damned equation!) rather than memorizing molecular structures.
It’s easier to understand than to memorize (for most of us, anyway… I think).
In medical school you memorize a lot but in practice you are better served by learning general principles. For example, I used to teach my residents that the answer to “How do you treat atrial fibrillation?” should not be “Coumadin and Amiodarone” but “first control the rate, second anticoagulate adequately, finally consider either electrical or chemical cardioversion”. If you learn this way then you won’t be thrown by the fact that medicine changes so rapidly.
For the afib example:
When I was in med school (IV Verapamil or B-blockers, IV Heparin/Coumadin, Quinidine or Procainamide)
By residency (IV Diltiazem or B-blockers, IV Heparin/Coumadin, above meds or Sotalol)
5 years ago (IV Diltiazem or B-blockers, LMW Heparin/Coumadin, Amiodarone)
Last week (IV Diltiazem or B-blockers, LMW Heparin/Coumadin or Pradaxa, Amiodarone)
Also remember that very little of actual practice is diagnosis. Most of medicine is management of chronic disease, particularly for specialists. That said, if you want to be a good diagnostician you do need enough memorized for symptoms to click in your mind and tell you what to look up. If you don’t think of malaria for a fever, you probably won’t consider it. Also, I still think that the physical exam is underrated. I like to think that I can pick up a lot with my exam. You can’t learn an exam from a book. That’s something you learn by doing it over and over again.
Out of curiosity, how much has the Internet changed the nature of medical education or practice? (I think this question is within the natural scope of this thread, but if it’s a hijack, I’ll take it elsewhere)
Patients come in with more information about the disorders that they’ve been diagnosed with, and you can have an intelligent conversation with them. In theory. In practice, the top hit on Google is rarely the right answer unless you know how to frame the question correctly, and throwing one symptom at Google will often get you to a community based around that one symptom. Which turns into an echo chamber real fast.
There’re many sites out there that let you pick symptoms from a list, and then tell you what disorders could present with those symptoms. Problem with that is that there are certain symptoms common to damn near all disorders, which will give you a list a mile long, starting with “common cold” and ending with “Krell-Macquarie-Ichinaga Intermittent Explosive Colorectal Neuroma.” Three guesses as to what people will be asking about when they come in, and the first two don’t count. A big chunk of med school, once you’ve done your memorization, is learning to apply practical principles like “when you hear hoofbeats, expect horses, not zebras, but check to make sure that it’s not a rhino just in case.” The memorization lets you pass tests, but as was mentioned upthread, most of medicine is not diagnosing that rare, once-in-a-career case. Most of medicine is being able to deal well with the things you see every day and having enough of a fund of knowledge that when that once-in-a-career case comes along, you get a feeling of “wait, this is odd,” and can research it in an intelligent manner and decide on a plan of action.
There is a lot to learn in medical school and it always seemed to me there are two basic strategies people use to do it: Rote memorization, as the OP suggests, and learning the basic principles and reasoning up from there, as DSeid and psychobunny nicely put it. No one can use one strategy exclusively, but people do seem to rely on one more than the other. As a pathologist, when I work with students I like to ask the question “What causes gastroesophageal varices?” If someone blurts out “Alcoholism!” then I know I’ve probably got a memorizer. If some one says “Cirrhosis?” then I know I’ve got a general principle reasoner type. Although people may start out relying on one more than the other, part of the process of medical school and training is to develop both. The really impressive people I’ve worked with were masters at both.
Oh, so it’s like organic chemistry? (IE if you just try to learn systems you won’t do well and if you try to just memorize you won’t do well either. I only did well when I figured out what parts needed to be memorized and what principles needed to be learned. Still I can’t believe the prof actually said there was very little memorization in orgo.)
Yes, I think so. I actually found organic chem to be one of the better classes for pre-med. Not because any of the information was at all useful to us as medical students let alone as practicing physicians later on, but because the process of learning and of problem solving needed to do well in organic chem has so much utility.
The fact is that most of the science facts you memorize and even the scientific principles you learn in pre-med and the pre-clinical med school years are little used after that; the learning that skill of memorizing what you need to and understanding what you can, of critical thinking (which can be learned outside of science classes as well), and of problem solving including taking the short-cuts (using heuristics) but always being on the look out for when they do not apply, are of more ongoing importance.
Probably true in many, if not most, other professions as well. And what is needed as a skill set as a practicing primary care provider is of course a bit different that what is needed as a pathologist or a radiologist.
Medicine is, when you get right down to it, pattern recognition.
The memorising is remembering what the bits of the pattern are- a list of symptoms, or biochemical blood values, or medication side effects.
The principle recognition is working out why that pattern of symptoms is caused by that disease, or why that medication causes those side effects.
But, when it comes down to it the skill, the “art” of medicine, is knowing why this headache is just a headache, and why that headache is a brain tumour.
In medical school you spend a huge amount of time practising how to take a full history and do a full examination.
You spend the rest of your practice trying to hone your skills so that you ask only relevant questions in your history, and perform only relevant parts of the examination.
A medical student might question you for 45 minutes about everything from your occupation to your sex life, and do a full neurological examination and cardiovascular examination and still come up with a diagnosis of “Headache- ?migraine ?tension headache ?space occupying lesion”.
A more experienced doctor might spend 5 minutes asking you pointed questions about your headaches and current circumstances, shine a light in your eyes, check your BP, poke your neck muscles and confidently tell you that you need to spend less time hunched over your computer because your bad posture and neck muscle strain is causing the headaches you’ve been having.
It’s the difference between a shotgun and a sniper rifle- and it comes only with practice. Eventually the things you’ve memorised and the principles you know inform what you do without you even realising it.