Sometime things take you by surprise. And like embers
glowing steadily the logic and thought ignite the spark into a fire. That is
exactly what happened when I read this article from the British Medical Journal
about Gamification of Graduate Medical Education (1).
I thought well, this seems like a nice idea to enhance
education. I read the article and came away with a different impression than was
sought by the Authors. “We named our
software Kaizen-Internal Medicine (Kaizen-IM). Kaizen, a Japanese word from the
quality improvement literature, signifies the need for continuous daily
advancement, a concept analogous to the principle of lifelong learning we seek
to inculcate in our residents.” Whereas they sought to prove that a
Kaizen-IM modelling technique helped ensure educational learning, reading
through the article I came away with the tortured use of statistics to prove
what they set out to prove. “Analyses
focused on acceptance, use, determination of factors associated with loss of
players (attrition) and retention of knowledge. Because traditional tests of
normality such as the Kolmogorov–Smirnov test, the Anderson–Darling test and the
Shapiro–Wilk test are subject to low power, particularly when the sample size
is small, continuous outcome measures were graphically assessed for normality
by investigating the distributional form of the outcomes using histograms. When
normality assumptions were not met, the appropriate rank-based Wilcoxon test
was used.”
But here is where it struck a chord and the tumbled notes
all fell in a crash of dissonance. “We
used the conceptual frameworks of user-centered design and situational
relevance to achieve meaningful gamification, including connecting with users
in multiple ways and aligning our ‘game’ with our residents’ backgrounds and
interests in furthering their education.”
Now why would that bother my internals? Learning by rote in
medicine is akin to getting ready for a Multiple Choice Q and A. Now hold on,
you power-jockeys of the esteemed elite schools! Think about Medicine as a
holistic mechanism for caring for the patient, not as a yes and no binary form
of interaction. I need a new paragraph to start that thought, so hold on…
The sheet of paper in front of you has many inked marks on
it as the proctor tells you “Start!” And away you go answering all the
questions within the bounds of the allotted time. Some, you skip and some you
hesitantly answer “C” as a hedge against the limited information in your brain.
By the time you are done, the mental exhaustion is replete with multiple rivulets
of sweat pouring down your back. You pass your answer sheet back to the
examiner and with one last look back at it, you figure, Okay that’s done! Three
months later you get a passing grade and you go celebrating till the wee hours
of the morning. Loaded with congratulations, inebriated from the slaps on your
back and feeling immune to the vicissitudes of mortal life. Ah yes, another conquered!
But then you enter the hospital and there lies a frail,
weakened human body, a shadow of its formal self as you can see the skin has
since loosened off and hanging on the bones with very little musculature
support. “What the…?” your words escape between your teeth. The breath from
this shadow comes in slow uneasy cadence, yes there is life but it is
struggling to maintain its domain within his shell. There is an odor that you
have never encountered before. It isn't obnoxious or anything, just a mousey, old
cat litter type, wafting through your senses. His eyes open and the whites of
the eyes are patchwork of miniature blood vessels and a hazy dull yellow background affixed onto an equally weak sallow complexion as deep pits on a desert floor. There are some spotty blood marks on his arms that lie above
the clean white sheets of his recently made bed. His utterances are feeble and
devoid of meaning when you ask him questions. He does nod in affirmance and
shakes his head slowly in the negative. Suddenly overcome with the complexity
of his person, you open his hospital chart and gaze through the lab reports and
his diagnostic x-rays. Ah! You think, here it is, the answers to the riddle.
This man has “such and such” and with “Mr. So and So, we will get to the bottom
of this,” you stride out of the room as fast as you can only to find that the
same tests had been done in this gentleman’s previous admission. Now what?
And there fellow journeyman, reader of these words, lies the
problem with gamification of medical education. Our entirety of purpose is not
in the hospital rooms, but in the confines of the computer glows where we
search for meanings, not in the operating theaters but in the virtual operations
conducted within the binary logic of a computer console, not with a patient-understanding
the look and feel of a disease but in the memory bank tied to a CPU, where a
differential diagnosis is within reach and Sutton’s Law is practiced for the
ideals of human care to safeguard finance and limit the use of limited
resources. When all you need to do is spend that extra moment in spending with
the ones with the ill health and recognize through expediency of critical thinking
what the problems are and which ones to fix now and those that can be fixed
later. It would limit running through the myriads of differential diagnostics
(that cost an arm and a leg and in many cases literally) and it would put the
resources to better use.
So here we are stuck in the conundrum of do little to save
the limited resources but use the tools that expand their use.
Time to rethink!
Time to reevaluate!
And maybe if we do, we will find the answer that is obvious
and time-honored…Spend the time with the flesh not with the automated binary
logic. Understand the human body and not the logic of a multiple choice. Draft
a memory of experiences that will recognize disease and help patients rather
than harming them with a “House MD” type approach of “biopsy the brain” when
fifty other things yield negative results in a span of one hour.
And about that EMR, there is nothing meaningful about it,
except more population-based algorithms!
No, medicine is and will be for the near future be practiced
with an art due in part to the humanness of humans and in part to the
connectivity between us humans. A discordant approach between the mind-body and clicks leads to de-coherence, which is futile in healing the sick!
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