Z? I told you so!

So the grades for my exam on saturday just came out. I did very well in genetics, and pretty well in microbes. The genetics exam was actually my best exam thus far in medical school, which is surprising considering I have always found genetics to be a very difficult subject. When we get our grades, they also tell us the Z score we achieved, which is the number of standard deviations from the mean that you were. Both Z scores were pretty positive, which means that I did significantly better than a lot of my classmates. On the grade distribution plot, however, there are always a few hapless souls who's Z score is in the -2+ range. School policy is that if you have a Z score less than -2, you failed the exam. I don't know how you could study for weeks and get a Z score of -3.2, but according to the chart, it's possible. Perhaps there was a family emergency or something. Alternatively, the person subscribes to the p=MD philosophy, though evidently they missed the part about p= passing your exams....

Sisyphus Was a Medical Student

Hippocrates fathered many of the ideals that are still revered in medicine. Fourth year medical school students recite the Hippocratic oath as they graduate and move onward, pledging to first, do no harm. Hippocrates originally stipulated that his students also bequeath their worldly goods to their instructor, a tradition that medical schools have also maintained. Other, less popular traditions have fallen by the wayside, for instance the moratorium on surgery or the fact that physicians were supposed to be celibate.

Recently, I also learned that Hippocrates instructed Sisyphus. Sisyphus was the first medical student in fact. Unfortunately, he didn't do well in his studies, and so, was doomed to repeat them until he mastered them. Current interpretations of Greek history maintain that Sisyphus was doomed to push a rock up a hill, not eternal remediation of medical coursework. This revisionist viewpoint is, however, erroneous.

Modern medical schools have modelled their curriculum on Sisyphus' experience. As with all modernization comes variation and improvement. Rather than endlessly repeat the same material, as Sisyphus did, which would in fact reinforce the facts, current pedagogical theory maintains that his experience is best mimicked by constantly changing the material. Today's medical student, then, is force to memorize dozens of pages of material, regurgitate for the exam, and repeat the process endlessly. Like the revisionist Sisyphus, the current medical student reiterates this pattern every 4 weeks. Since the human memory is finite, the hard work put in by the medical student is for naught, ulitmately. Though he may kill himself trying to learn the material, by the end of the next block, the previous block's material is 80-90% forgotten. He can take grim comfort in knowing that ulitmately cramming immunology is fruitless because by the end of the term, it will be as though he hadn't learned it at all, and the minute amount of retained knowledge was the information that was already in place before the course. I love medical school.

Cold

Well dear readers, I haven't much to say. It has been a cold week here in St Louis. Today the low was 9, yesterday the low was 8. Fortunately, our heat has been working so our little hut stays nice and warm. Mindy and I went ice skating at Forest Park at an outdoor rink there. It was quite a nice evening. We've resolved to do more dates this year and skating was a nice start. Several hundred other people must have had the same idea however, since the rink was quite crowded. Also in keeping with new year's, I have been running three times a week with Mindy in Tower Grove Park. It's really nice to get that sympathetic stimulation in the morning to jump start my day. I still study all day long, but at least I don't feel like I'm getting more and more sluggish as they weeks progress.

We had ward conference today, which was meant to be an abbreviated block so we could "have the final session in our homes." What that meant however, was that I was at church for 5 hours instead of the usual 3. We had trainings for the Elder's Quorum and a Ward Council to attend. Sacrament meeting was pretty good, with the exception of being 2 hours long. There were several people called up from the audience to speak, but some of the talks felt like they were just there to take up time.

School is school, by which I mean that it's still like drinking from a firehose. I feel like I finally have a handle on the stuff that was presented at the end of the first week, leaving me all of last week's material to master. Immuno is pretty interesting. Genetics is ok. THe one downside is PBL sessions which we are obligated to attend.

For the uninitated, PBL stands for Problem Based Learning, and is a curricular element that, while all the rage at medical schools, is mercifully absent from most of my curriculum. What is supposed to happen in PBL is that a group of 10 students with a faculty moderator review a case weekly. Between sessions the students do lit searches on various subjects and report back the next week. At the next session we all share our information and the next portion of the case is revealed. THe theory is that we are supposed to learn to present things, do lit searches, and of course learn about the material in question.

Some of these things actually happen in reality. We do in fact learn how to do lit searches, and we do present things to one another, supposedly mimicking case presentations that happen on the wards. What really happens, however, is that we wind up being "experts" on some trivial minutae and never really learn what our colleagues researched. Sometimes the lit searcehs are incredibly time consuming as well, sapping valuable time from studying genetics or immuno. The PBL sessions are 45% of my grade, which means it behooves me to do a good job, and relieves me of the burden of some exam studying, since each exam is only 18% of my grade then. Fortunately we don't spend as much time in PBL as a lot of the other groups, which means I can study T cell activation even more!

I hear you, though. YOu are thinking, why doesn't Spiff care about collaborating with his colleagues? Doesn't PBL provide the relevance factor that Spiff is always complaining is missing in lecture? Isn't it nice to learn in a different way every now and then? Wouldn't it be much better to have self directed learning all the time, since you're more likely to remember what you find yourself? Spiff will now field these questions.
-RE: collaboration: PBL isn't collaboration. It's lots of separate people contributing to a discontinuous and unorganized whole.
-RE: relevance: PBL doesn't introduce relevance necessarily. Instead we get bogged down in the minutae of say the mechanisms of isochromome 6p formation in retinoblastoma. The potential is there, but relevance is not necessarily associated with PBL
-RE: Different learning modality: See also -time wasting
RE: self directed learning: Yes, it is true that I tend to remember stuff that I research myself. BUT, on a per unit time, PBL is really inefficient. I talked to our moderator about this in private, and he said that PBL is not designed to be an efficient learning tool in terms of volume. It is more to practice the interpersonal skills. Great. I already know how to give talks and presentations.

It is some consolation that at least my group mates aren't total tools, which is the case in some groups. We have several ground rules which keep things moving briskly too.
-NO powerpoint
-NO presentaion over 3 minutes
-Yes treats every week
-1 page max on any handouts

AT least PBL is only weekly and fortunately it isn't too big of a waste of time.... though we'll see what I say as the term progresses.
-Spiff

Evidence Based Medicine

BMJ 1999;319:1618
Seven Alternatives to Evidence Based Medicine

David Isaacs, Dominic Fitzgerald

Clinical decisions should, as far as possible, be evidence based. So runs the current clinical dogma.(1, 2) We are urged to lump all the relevant randomised controlled trials into one giant meta-analysis and come out with a combined odds ratio for all decisions. Physicians, surgeons, nurses are doing it(3–5); soon even the lawyers will be using evidence based practice.6 But what if there is no evidence on which to base a clinical decision?

Participants, methods, and results

We, two humble clinicians ever ready for advice and guidance, asked our colleagues what they would do if faced with a clinical problem for which there are no randomised controlled trials and no good evidence. We found ourselves faced with several personality based opinions, as would be expected in a teaching hospital. The personalities transcend the disciplines, with the exception of surgery, in which discipline transcends personality. We categorised their replies, on the
basis of no evidence whatsoever, as follows.

Eminence based medicine
The more senior the colleague, the less importance he or she placed on the need for anything as mundane as evidence. Experience, it seems, is worth any amount of evidence. These colleagues have a touching faith in clinical experience, which has been defined as "making the same mistakes with increasing confidence over an impressive number of years."(7) The eminent physician’s white hair and balding pate are called the “halo” effect.

Vehemence based medicine
The substitution of volume for evidence is an effective technique for brow beating your more timorous colleagues and for convincing relatives of your ability.


Eloquence based medicine
The year round suntan, carnation in the button hole, silk tie, Armani suit, and tongue should all be equally smooth. Sartorial elegance and verbal eloquence are powerful substitutes for evidence.

Providence based medicine
If the caring practitioner has no idea of what to do next, the decision may be best
left in the hands of the Almighty. Too many clinicians,unfortunately, are unable to resist giving God a hand with the decision making.

Diffidence based medicine
Some doctors see a problem and look for an answer. Others merely see a problem. The diffident doctor may do nothing from a sense of despair. This, of course, may be better than doing something merely because it hurts the doctor’s pride to
do nothing.

Nervousness based medicine
Fear of litigation is a powerful stimulus to overinvestigation and overtreatment. In an atmosphere of litigation phobia, the only bad test is the test you didn’t think of ordering.

Confidence based medicine—
This is restricted to surgeons.

Comment
There are plenty of alternatives for the practising physician in the absence of evidence. This is what makes medicine an art as well as a science.






Contributors: DI and DF each contributed half the jokes and will
both act as guarantors.
Funding: None.
Competing interests: None declared.
1 Evidence Based Medicine Working Group. Evidence-based medicine: a
new approach to teaching the practice of medicine . JAMA 1992;268:
2420-5.
2 Rosenberg W, Donald A. Evidence based medicine: an approach to
clinical problem solving. BMJ 1995;310:1122-6.
3 Sackett DL, Rosenberg WM, Gray JAM, Haynes RB, Richardson WS.
Evidence based medicine: what it is and what it isn’t . BMJ 1996;312:71-2.
4 Solomon MJ, McLeod RS. Surger y and the randomised controlled trial:
past, present and future. Med J Aust 1998;169:380-3.
5 McClarey M. Implementing clinical effectiveness. Nursing Management
1998;5:16-9.
6 EBM and the IMF. J Exponential Salar ies 1999;99:1-9.
7 O’Donnell M. A sceptic’s medical dictionar y. London: BMJ Books, 1997.

Short reports
Departments of Education and Medicine, New Children’s Hospital, Westmead, NSW 2145,
Australia

David Isaacs clinical professor, Dominic Fitzgerald staff physician
Correspondence to:
D Isaacs
davidi@nch.edu.au
BMJ 1999;319:1618
1618 BMJ VOLUME 319 18-25 DECEMBER 1999 www. bmj.com


Thank you British Medical Journal for a little levity!
-SS