Wednesday, September 29, 2010

Teachers and Students in Medicine

                                              Knowledge (statue in Turkey)

All hail to the teacher. And yet what has become of the student? The ignominy that resides in hubris leaches out slowly and steadily into our reality. We the teachers now expressively ensconced on the upper rung of the ladder given grief from the publish-or-perish-world conspire to manipulate data to suit the world’s thirst for knowledge. We the teachers face the glut of questions answered with the thin veneer of specialized words that mean nothing and impart nothing. We the teachers hatched into a world belaboring to achieve fame and recognition lose sight of the young student that puts out his or her hand and asks, “May I have a little more sir!” This little person with a brain that is a sponge for knowledge is left threadbare with patches of knowledge, a confusion of ideas and a dose of cynicism that will fit the mosaic of a future reality.

What is it that inspires a teacher must undoubtedly inspire the student. And yet if the inspiration is drawn purely from a function of self-advancement, then all hope for the fundamental grant of imparted knowledge becomes riddled into the fabric of misappropriated facts. It is from this misunderstood and fragmented knowledge base that the mind of the student must grow and encompass and learn to practice in the minefield of human-diseased indignity. How can they, in all likelihood, ever accomplish such lofty goals?

I remember those days when I was a student. They were heady days long in the hour and short on time. There was a constant barrage of questions and answers, some answers were short but paved the way to search for more details while others were to the point needing little exposition. The battle of wits continued between the student and a bevy of very smart, considerate, careful and thoughtful teachers. These were the old guards. Their purpose was to educate and create the models from which new knowledge would sprout. They felt pride in calling someone their student. Their pride flowed in the words “my student.”  We were their calling card.

But most of that is gone now. Today the race to produce circumvents all such glory. The race is all. There is nothing but that race. The teacher walks into the lecture hall rushed for time, gives out a test and sits down at the desk to contemplate his own issues. Remarkably, the students have come to know that never is any time to ask questions. Just listen keep quiet and maybe skip classes and then cram by rote from the textbooks before an exam and graduate with a degree. Some students yearning for better grades espouse the cause of the teacher and become embroiled in the “scientific trials,” only to become what the teacher is.

And there in lies the problem, a perpetuity of this distress. What insights might the student have gathered from the textbook about the clinical nature of his understanding about medicine? He might as well have seen the TV show House, MD and come to a conclusion that irreverence to others including patients and their families is the hallmark of being a physician as long as you can call for every diagnostic test and probe and biopsy any and all organs of the body to determine the malady which, I might add may be determined in large measure with a simple art of history taking and thorough examination. Yet, House MD an actor with no knowledge of medicine and far less as a sympathetic human being, watched by millions as a recalcitrant intellectual, is idolized as a hero. My, My what have we come to? And no you don’t have to become a Sherlock Holmes and trespass into someone’s home to determine there is mold to realize that a fungal pneumonia is a possibility in an immuno-compromised host. It all stems from a dysfunctional nature of thinking. The very essence that makes us humans has been slowly and quietly through mechanisms of studying the study habits and measuring the measure of accomplishments or deifying a phenomenon of teaching that lasts a season of endearment, we have lost and tripped onto this societal debacle.

When did it all go so different that now we need to analyze “how to teach?” and “how to learn” There are countless articles and books and magazine reviews about the art of learning. There are empty words that skim the surface of intelligence amongst the discussants who sit with their noses turned up high and their brows touching their hairline or if not, wrinkling the elegant bald scalp that gives them the air of arrogance, but through all this chicanery, does nothing for the students. Words like “Metacognizant” and “Concept Map” and “Mind Map,”  resound in the circles of these ivory tower individuals that have become so bloated from self that their ballooned faces have turned their eyes into slits from whence they cannot see.

The function of teaching is to educate the student with the known knowledge. This knowledge is not abstract. The basic building blocks are the firmament of Anatomy and Physiology. From there the Pathos that inhabits the human body can be understood. From the knowledge of Embryology a branch of Anatomy becomes the building block of childhood disorders dealing with malformations such as the 

Tetrology of Fallot and Dextrocardia. Equally, knowing the basic understanding of the Kreb’s cycle can help in the understanding of hypoxemia and its effect on various organs and from there to the acid-base disorders that do ensue. It is not the temporary, the latest, the trendy knowledge wrapped in a euphemistic term called "evidence." It is the deep unchanging rule of nature. It is fact.

Similarly understanding the cell growth cycle and the proliferation of the cells into daughter cells hastens the knowledge of how malignancy starts and spreads and how medicines like chemotherapy counteract this wayward behavior. From there the students can garner knowledge of the cell surface receptors that line every cell surface and respond to the various antibodies, hormones or specific chemicals and through knowing this reward themselves with the understanding of the intra and intercellular pathways that motivate the cell to grow, divide and multiply.

The building blocks to “know” medicine are essential to the gaining of a foothold into the reality of disease. Knowing and citing literature about esoteric and unusual medical cases may seem smart and lofty but it isn’t. It is true that the knowledge and understanding of diseases keeps changing like the shifting sands of time, yet the basic mechanisms of health remain constant. Build a strong foundation and the structure shall survive a large measure of time. The gifted Sir William Osler, MD was one such teacher that touched the pinnacle of educating students.

               Sir William Osler, MD

Physiology teaches us the mechanisms of normal activity of each organ and the combined pool of organs within a system. Since most organs are interconnected with vasculature and neural supply they, the organs talk to each other via chemical and neural circuitry. An assault on one is an assault on the entire soma. Learning about heart failure is not about learning the thousands of medicines that keeps the contractility of the heart muscle, nor is it about the extra fluid buildup that needs to be purged. What it is, is the knowledge of heart muscle’s decline from impeded vascular supply or overworked fatigue or age and the congested channels that flow into it, the organs that get flooded with extra blood and become dysfunctional with the excess fluid within their tissues. 

The liver so congested cannot process the food hence the patient loses his or her appetite. 

A continuous congested liver leads to bile-flow stoppage which shows up as jaundice and equally in that chain of events, the inability of the congested kidneys from filtering the excess blood from its waste-products leads to acid-base disturbance from the electrolytes, leading to acidosis. This excess acidity creates a damning effect on the blood factors contained within this humor, which can ultimately lead to a disseminated intravascular coagulation that can cause spontaneous bleeding from any site and can be fatal. It is from here to there to everywhere! 

So the vehicle that transports the “waste” is equally important as the heart that pumps the blood, which is  as important as the liver that filters the food products and makes the blood factors that keep the blood in a congealable state. In essence the cumulative damage from a single organ mishap leads to a multi-organ dysfunction. It is in this measure of understanding that the furtherance of knowledge is achieved. The connectedness of it all!

                         The Doctor by Luke Fields

Once the basic building blocks are firmly entrenched the nuances of each block can then be enhanced with additional information. Knowing the information without the basics is impressive when mouthed but in reality does little for the patient’s health or the physician’s advance in understanding.

So students of medicine, that we all are as physicians, must renew our association with the building blocks now and again to keep ourselves in the loop of understanding.

And teachers of medicine remember the time you are spending with the students is more important then the hours spent citing literature to your cohorts. If you are after fame, remember that the student will echo your name throughout his life. The Galley proof that is held in your hand that makes you expand your chest will soon be placed in a heap; forgotten. It is better to be a giant upon whose shoulders the student learns to stand on and see where others fail to, then an empty suit that hollers and demands silence but gives little in return for that demand. If you are after educating then you are the teacher the student will walk with in lockstep.

Can teaching be mandated and in the same vein can learning be forced? The answer is obvious to all. No and no. Where a student desires to learn and a teacher is passionate to teach the combination can have far reaching benefits for the student and the society in general. It is the passion that emanates from the deliverer of the message and the desire that resides in the receiver, which makes for a great future. It is a powerful reach into the expansion of understanding that is devoutly to be wished. 

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