From: doyle+@pitt.edu (Howard R Doyle)
Newsgroups: sci.med
Subject: Re: Indoctrinating Interns
Date: 31 Jul 92 12:21:06 GMT
Organization: Pittsburgh Transplant Institute

In article <1992Jul30.162823.254@falcon.navsses.navy.mil> dzimmerman@falcon.navsses.navy.mil writes:
>>...a reasoned arguement about force-training interns....
>
>I hate to jump on this, because it sounds so reasonable.  But it is,
>of course, utter BS.  Doctors are the only profession I know of that
>train this way--and it's about the single worst way to train anyone
>for anything.  I can't drag out statistics, though I know that
>studies have been done, and are being done.  But I can speak from
>military experience and threory.


I missed the original posting that prompted this response. And this is
one of those topics with the potential to become as heated as the diet
holy wars, so I'm also a little hesitant to jump into this. On the other
hand, I think most of you educational experts out there may benefit from
our perspective, though I admit we may be hampered by years of first
hand experience.

>If you want to train someone in something...anything...you drill,
>drill, drill.  And you go out of your way in the training schedule to
>ensure that the trainee is reasonably rested and in good shape because
>tired bodies make for tired minds.  Class work in the morning and drill
>in the afternoon, for instance.

This is all well and good when you can schedule things ahead of time. But 
during my surgery training more than half of the operations I performed were
done at night or during the weekends. Emergency surgery tends to be that
way. So after being up all night putting Humpty Dumpty back together
again, I had to work a full day (on the wards, clinic or back in the O.R.),
certainly not at my best. 
In your ideal world this would not happen. In your ideal world I would have
gone to bed the next day, and come back 24 hours later, well rested. But my
residency would have taken ten years instead of five. Motor skills are
acquired only after seemingly endless repetition. And that elusive quality
called clinical judgement has to be developed on the field, because no two
patients are alike. And then there is the issue of continuity of care. When
folks come into the hospital they immediately assume they have the right to
get sicker or develop complications on any day of the week, at any time.
Having to deal with these ups and downs is what teaches us what to expect
in a given clinical situation, and how to anticipate them in the future. And
this is just the training aspect. If I'm sick and suddenly take a dive, I sure
as hell hope that the guy that comes to see me is intimately familiar with
my problem, and not just some night shift replacement who's going to have to
look long and hard at my chart and start thinking about me for the first time.
It takes a long time to train a clinician, especially one that deals with
critically ill patients. It cracks me up when folks in high stress fields,
like statistics, decry our current training methods. When someone's blood
pressure is no longer there I'm supposed to know exactly what to do, not 
just where to go to look up the answer.



>I can look at the way medicine is taught today, and tell you exactly what
>it is for--and it's only indirectly related to medical knowledge.  The
>repetitive drill aspects do tend to emphasize learning--but they would do
>that in the same way in any structured program.  The pressure is simple
>indoctrination, however subtle.

Those of us who train physicians are as interested in teaching medicine as
we are in indoctrination. And believe me, we are not subtle about the
indoctrination part. By the time we finish our training we need to have
acquired a couple of things. First is a truckload of factual information,
which will allow us to be competent at what we do. The second is a mental
attitude, one that makes our patient come first, even at the expense of
our personal life. This is what allows us to be good, not merely competent,
at what we do. And it is this second aspect of our training that is the
hardest to achieve. And it is done through indoctrination. And I don't feel
we need to apologize for doing it. Especially in this group where we catch
so much shit every time someone runs into a doctor who is either not very
competent or not very caring.
-------------------
Howard Doyle
doyle+@pitt.edu