Something about this Ebola case in Texas that caught my eye.
A nurse took the patient’s history during his first hospital visit. The history
included a statement saying the patient mentioned that he had recently traveled
from Africa. In retrospect, that statement became super important. I heard
several people, medically trained as well as layperson newscasters, state unequivocally
that had a “doctor” heard that, he or she would have known the patient had Ebola
virus, which may be true but no necessarily so. Let me explain something about medical
education that I have been arguing for years.
In a recent exchange of letters with a Dean of a college, I
pointed out that this dean had bowed to social pressures to change the
curriculum in his college. After years of bureaucratic nonsense of collecting
opinions, taking surveys, and forming committees to study this or that, the
curriculum was changed; in my opinion, the college (the Dean) changed the curriculum
in a disastrous way. The Dean was the only person who could have prevented it
from happening, but didn’t. Admittedly, the social pressure on the Dean from students,
college professors, the medical community as a whole, and from society was
intense. In this case, the Dean not only approved the change but also promoted it.
The totality of “medical knowledge” that has accumulated over
time is breath taking. It is not only massive and sweeping but also expanding
at an accelerated rate. It is much more than anyone person can know or even
groups of persons can know. Thus, college administrators divide the massive task
of medical education into manageable subunits: undergraduate, professional
school, and postgraduate education. Educators have further divide postgraduate
education into PhD for bench researchers and residencies for specialties and clinical
research. In addition, administrators integrate nursing, and technical
education as part of medical education, which are a big part of the overall
picture. Thus, administrators have divided the technical and professional curricula
into two huge areas. The nomenclature that has developed surrounding this division
is awkward; of course, nurses are professional; nevertheless, the term ‘professional’
applies to the medical doctor or the veterinarian, while the term technical
applies to all who the public charge with the responsibility of helping to
carry out the overall objective, which is health care.
Most people seem to have a grasp of the concept of ‘professional’
verses ‘technical’ knowledge over the doctor nurse divide. Jokingly we hear
people say things like, “nurses can do everything but doctors know everything”.
However, the sad truth is that students of medicine seem to have not applied
that conceptual difference to their education. Medical students see themselves as
highly respected individuals in white coats or surgical scrubs with stethoscope
casually slung around the neck practicing medicine—doing things—as they have
seen in hospitals and doctors officers. They want to achieve that status as
quickly and effortlessly as possible. They have led themselves to believe that
practicing medicine is doing these things. It is not; practicing medicine has
to do with what is going on in their heads; nursing is doing things. Of course,
there is tremendous over lap.
Students do not see setting in lecture after lecture as
learning about exotic diseases and circumstances that rarely happen as well as
the everyday things that can and do go wrong. In their minds, the clinic is
where they learn medicine not the classroom. Consequently, they push for their college
administrators and professors to eliminate lectures or at least cut them to a
minimum and to expand clinic exposure time. The history of medical education is
the story of a shift from apprenticeship programs to academic program; students
want to reverse that trend.
The patient suffering from Ebola entered the hospital. More
and more physicians are trained, as one doctor said during a recent interview, they
are trained to look for horses if they hear hoof beats and not to worry about
zebras. Every nurse in that hospital can diagnose common colds, mild and severe
flue, allergic reactions; everyday stuff but there is only one who sat through
boring lecture after boring lecture where some professor described zebra. Diseases
that they could never learn through an apprenticeship program that is by personal
experience. The signs and symptoms and the distribution of dengue, falciparum
malaria, sleeping sickness, Ebola, etc, etc; one boring disease after another,
disease the nurses have never heard of or have the slightest idea of how to
make a diagnosis.
That nurse should not be expected to be able to diagnose exotic
diseases but the physical should have because that is his or her job. However,
the failure to diagnose the Ebola patient in the first hospital may not have
happened even if the nurse had told the doctor the patient came from Africa especially
if he or she was a young doctor recently graduated from a medical school where
the students had undue influenced over the curriculum turning medical education
back into an apprenticeship program. It is extremely unlikely under ordinary
circumstance that the nurse or even the doctors in that hospital would have recognized
the signs and symptoms of Ebola and referred the patient to an exotic disease specialist
if the popular press did not have the Ebola epidemic in the headlines. I think
the medical community acted in an exemplary way in Dallas. The question remains unanswered; are our physicians now “highly trained
nurses” and are our medical specialist becoming what physicians used to be. If
this is the case, it represents a sea change in medical education made in
response to the exponentially expanding knowledge and we should recognize it as
such.
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