Thursday, October 31, 2013

Are We Using The Wrong Tools To Mold Doctors?

Readers of the revitalized Meditations on Medicine blog will know that I'm alternating between articles about medicine and recipes for my favorite foods. This week, will be more of an editorial, a softer article, rather than an explanation of recent developments in the world of hard science.

Some of you may remember an article I wrote some time ago about the three most important non-science courses a doctor should take - in it, I argued that social sciences, languages, and the arts had an important role to play in a doctor's education. This week, I'm going to follow up on that theme and ask whether the way we test and select doctors isn't having some unintended consequences.

A few years ago, the School of Medicine at Mount Sinai opened a program that send aside places for students who had not merely focused on the liberal arts in college, they had even been allowed to skip organic chemistry, physics and the MCAT (Medical College Admission Test). The goal was to produce clinicians who were not merely scientists, but compassionate healers. This article was the background of my interest, although my inquisitive mind has taken things a bit further.

I'm not going to question that doctors should be educated in the basic sciences. I'd even argue that skipping over organic chemistry and physics isn't necessarily a good idea. Organic chemistry, often derided as a 'weeder class,' in fact plays an important role as a 'weeder class.' A medical education takes a lot of work, and organic chemistry is nothing if not a lot of work, so it's a good measure of an applicant's ability to be up to the task. And physics, well, physics... You know, actually, physics may not be that important for most clinicians.

However, I do think that the way we elect students through standardized testing, and specifically multiple-choice questions, has had some unintended consequences.

Standardized testing and multiple-choice questions are the gate-keepers to a medical education. With the exception of the program listed above (and a few others like it), you cannot get an education in a healthcare field without demonstrating your ability to succeed at answering multiple-choice questions. Additionally, your advancement within the field is also governed by your ability to excel at this type of test. As a result, the medical field has selected for people who can succeed at this task, and have been trained since at least high school that the best way to assess a situation is through a multiple-choice format.

I'll just quickly outline what I mean. As anyone who's taken a multiple choice test can answer, in a given question, there is typically only one piece of information that enables you to answer the question - the majority of what's written is chaff, and it's your job to ignore it, cut to the chase, retrieve that piece of information, select your answer, and move on to the next question. For example: "A woman blah blah blah blah was visiting a friend's farm blah blah blah." The answer: She's got leptospirosis, which she caught from a cow. Another example: "A male Egyptian patient blah blah blah..." You don't even need to keep reading. Eastern Mediterranean = he's got beta thalassemia. On to the next question.

Why does this matter? The American public are frustrated with their doctors. Many patients are tired of short visits, brusque clinicians, and prescriptions with no explanation. Unfortunately, I think this at least partly stems from multiple choice questions. Visits are short and doctors are harried because they're trying to cut through the chatter and get the one nugget of information that will give them the diagnosis. When they've gotten that piece of info, it's on to the next bit, where they again make a multiple choice selection of a drug. We're frustrated with our medical system yes, but unfortunately, we have set our system up to select the people who are the very best at doing this. We've trained them to think this way, and shouldn't be surprised when they treat us this way.

This is a big problem, one that will resist easy fixes. However, though we may have difficulties in solving the problem on a large scale, we can still take steps to solve the problem in our personal lives. There are healthcare providers out there who do treat their patients like complex systems that deserve adequate assessments. Some are primary care providers, some are naturopathic doctors, some are other health professionals. Whether you have a problem that requires an essay to respond, or can be written in a short paragraph, seeking out a provider who listens to what you're saying and responds in kind is well worth your while. What you say isn't just a distraction getting in the way of the answer - it has value. You deserve to have your whole story heard.