Personal View: Unlearning
Authors: Chris Johnson
Journal: BMJ (2005)

Senior clinicians are often castigated for being out of date. Rapid developments in technology and frequent alterations in evidence based guidelines make it difficult to ensure constant modernity. But does neuronal loss incapacitate the senior clinician? Are young people inherently more receptive to new ideas? Or are other mechanisms at work? Dame Janet Smith suggests that revalidation should require doctors to pass regular summative knowledge tests. No doubt educationalists will seek to develop fair, validated, and defendable examinations, and we will face some form of multiple selection questionnaire, probably linked to a visit to a simulator to resuscitate a plastic doll. An industry will establish itself around such tests, and—given time, a few courses, and plenty of practice—I might hope to surmount the hurdle.

But my fear is that, as a senior adult learner, I will be expected to conform to methods of teaching, learning, and testing that alienate me. I suspect that younger doctors will find it easier to pass the tests than I shall, not (I hope) because I am on the path to senility but because they have less to unlearn. My 1960s education consisted of didactic discourses linked to ritual humiliation and the threat of violence from masters or peers. A safe learning strategy was to keep your head down and your mouth shut and avoid attracting attention. And I became very good at this. My daughter's schooling has produced few basic science problems that I cannot solve, even though I have not thought about physical chemistry or the physics of light for 30 years. But I loathe being forced into artificial situations in simulators or moulages; I cannot suspend reality.


Errors I make in following the current fashion reflect a retentive memory, not approaching senility


Medical school was a joyous apprenticeship. I listened carefully to experts, made notes, and formed my ideas by comparing the opinions of others. Nowadays, of course, interactive groups, facilitated learning, and plenary report-back sessions have replaced such direct methods of learning. We sit debating inefficiently for 40 minutes, argue about who reports back, and watch politely while a guru covers a whiteboard in random scrawl. There is nothing for me to latch on to, note down, and remember. I return home clutching a continuing medical education certificate, feeling cheated that I have paid money that no one has earned.

It's not just learning techniques that must be unlearnt: clinical protocols too change with time. But unlike a computer hard drive my mind does not replace old information with new; the original remains intact to confuse. My retentive mind can still visualise the guidelines on cardiopulmonary resuscitation I learnt at medical school. I was taught well—a process reinforced by years of attending arrests. In the 1970s the compression to breath ratio was 5:1, with 60 sternal compressions a minute. Imprinted on my mind are the specified doses of bicarbonate, calcium, and “lignocaine.” But nowadays this imprinted knowledge could potentially fail me during advanced life support testing.

Theoretically I know that the arrest box now contains adrenaline, atropine, and amiodarone, that biphasic defibrillators require 100 joules not 360, and that 5:1 evolved to 10:2, to continuous, and ended up, at least for now, at 15:2. But this knowledge only overlays the old, and I feel uncomfortable recalling it, knowing that although the theory is evidence based, ward survival after cardiac arrest has actually altered little since my days as a preregistration house officer, and knowing that the resuscitation guidelines will shortly be re-revised, so the entire workforce will again be rendered out of date.

Unlearning is becoming fashionable. An internet search for “unlearn” reveals sites in which people are challenged to alter their fundamental beliefs regarding religion, sexuality, or business prowess. Learning something new is easy; unlearning something old is difficult. Unlearning is not the same as forgetting. Forgetting enables you to start again without the problem of trying to resolve conflicting information. Unlearning is far more challenging, because you have to alter information, and in so doing you have to challenge your beliefs. Unlearning a fact implies that all the time spent learning it originally was wasted. Unlearning a method of learning requires fundamental alteration of your mental processes, even though the original way worked perfectly well for you. The dividends of unlearning are negligible: after much effort you still possess the same amount of valid knowledge. Maybe that's why we become grumpy old people.

So, to all those management consultants and psychologists who make a living out of facilitating our thought processes, I offer this: think about unlearning and teach us all how to do it. I predict a great future for unlearning. But in the meantime, if you wish to revalidate me using guidelines on advanced life support bear in mind that I know five sets of guidelines not one, and that errors I may make in following the current fashion reflect a retentive memory, not approaching senility.