Knowing everything about every disease

As the practice of medicine has become increasingly complex over the past few decades, the amount of knowledge that someone studying medicine theoretically needs to accuulate and retain is now well beyond the intellectual capacity of any human being. Medical education has increasingly recognized that it is impossible to teach trainees everything about everything, and equally impossible for medical students and residents in training to learn and retain everything.

To overcome this problem, medical educators have developed two strategies. The first is to recognize that since certain disorders kill and maim more patients than others, we tend to spend more curriculum time ensuring that students learn about these critical problems, leaving little time for less serious disorders. Thyroid disorders, although debilitating and in some cases devastating, seldom kill or maim, and they are only part of one medical specialty. They are therefore given little curriculum time, even though they occur commonly in the population, whether in North America, Europe, Asia or in other parts of the world where there is severe iodine deficiency.

The second strategy is to continually impress on their students that they must become lifelong learners. Thus, attempts are made, in both undergraduate and postgraduate training, to teach trainees how to learn for themselves and where to find information resources. This approach will not only allow trainees to keep up-to-date but help them gain new knowledge and skills. Indeed, the approach is similar to that used by many patient thyroid organizations in helping their members find reliable sources of information such as support groups, libraries and the internet. So in a broad sense, thyroid patients are also trainees.

What clinical competence is all about.

To practice good medicine, physicians need to be clinically competent. Clinical competence is not an easy concept to understand. It includes things like taking a patient's history, carrying out an appropriate physical examination and acquiring other data such as results of blood tests and x- rays. Having gathered all this information, the physician then needs to solve the patient's problem by diagnosing it and treating it. As part of all this the physician needs to be able to communicate in a compassionate and meaningful way with patients. They need to listen carefully to what their patients are telling them.

Clinical competence requires knowledge, skills and appropriate attitudes. Knowledge is the easiest of these to understand, teach and measure. Knowledge is basically information stored in the learner's mind. Either they know it or they do not. Skills, such things as examining the heart or feeling the thyroid gland, are actions that must be performed in a competent way to achieve a goal. Skills are much more complex than knowledge to teach and test, harder to master, and in many ways much easier to lose and forget. Unlike knowlege, where the learner either knows it or does not, an individual may have a little skill, a moderate amount of skill or complete skill. For example, a beginning student can examine a thyroid properly but not pick up abnormalities when they are present, the resident in training picks up the more obvious abnormalities, the expert misses nothing. All have some skill in thyroid examination, but their level of skill is different.

Attitudes have been defined as feelings about an object or concept that result in a tendency to act in either a positive or a negative way. To a large extent, attitudes are determined by an individual's personality. By our late teens, most of us have already formed our personality and it is very difficult to change. Probably the most important thing determining the attitudes of those who graduate from medical school is the attitudes they have when they enter medical school. When it comes to relationships between doctors and patients, attitudes, good or bad, seem to be the greatest factor in determining how good or bad these relationships are. Competence in a clinical situation involves the complex ability to apply appropriately these three attributes - knowledge, skills and attitudes. They form the basis of all clinical practice.

How people learn: deep memory

Learning involves getting knowledge, skills, and attitudes into memory. But there are two types of memory. The first involves superficial learning, the second involves deep learning - that is, getting what has been learned into deep memory. When learning is superficial, students remember words and phrases. They can only remember a limited amount at any given time. What has just been learned is very vulnerable to being displaced by what is learned immediately after. In other words, things learned in a superficial way are not remembered for long. As medical educators, our real goals is to make sure that learning gets into deep memory, beyond memorizing words and phrases. This involves comprehension and understanding and lasts for a long time. A number of factors are know to facilitate deep learning. Medical teachers, themselves, must be taught to understand and use teaching strategies which ensure that most of their students' learning is deep rather than superficial.

How doctors reason: testing the key cases

As we have seen, knowledge, clinical skills and appropriate attitudes form the foundatin of those who practice the health professions. But clinical diagnostic competence goes byond these basics. It involves what is called clinical reasoning - that is, how doctors think their way through patients' problems to come up with the correct diagnosis.

We now know that the cases encountered during training form the basic fundamental framework for how doctors diagnose. It appears that a basic set of medical problems or types of medical cases underpin the reasoning that takes place when a doctor is trying to diagnose a new patient. Throughout the course of taking the history and carrying out the physical examination, doctors are constantly thinking of possible diagnoses, comparing them to cases that they know and have seen previously, and discarding one after another until they are left with what they suspect is a correct diagnosis. There seems to be a relatively small number of these key or prototype cases - possibly as few as 150. These are common and important diagnoses around which most practicing doctors reason when they are tyring to diagnose a patient with a problem that they are seeing for the first time. It is somewhat like the case work of Sherlock Holmes, a process of deduction.

This understanding of how doctors think when they are making a diagnosis is relatively recent. It carries one very strong and important message. If students have never been exposed to some of these prototype cases during their medical training, they are unlikely to be good at diagnosing new patients.

If it is important to ensure that students have the appropriate knowledge, skills and attitudes before they are allowed to practice medicine unsupervised, it is just as important to ensure that, during their training, they have been exposed to the wide variety of common key cases around which doctors reason when they are trying to make a diagnosis. If students have never seen a case of hyperthyroid Graves' disease, they will have great difficulty in diagnosing hyperthyroidism from any cause.

Putting it all together: What can Medical Education do?

Unlike diseases in other specialities, diseases of the endocrine system are frequently hard to diagnose because hormones affect all parts of the body. In many other specialties, where the clue to the diagnosis often likes in a single symptom in a given organ system, for example, diarrhea as the presenting symptom of gastrointestinal disease, or chest pain pointing to coronary artery occlusion. But endocrine disorders, the thyroid included, usually present with a number of non- specific symptoms, such as tiredness, nervousness, dry skin, etc. Diagnosing endocrine diseases usually requires what is called pattern recognition. The problem with pattern recognition is that if you have never seen the pattern before, you are unlikely to recognize it and make the diagnosis.

Thyroid disorders are common, but they are generally treated as outpatient disorders. Since much of the training of medical students and residents takes place in tertiary care hospitals, students do not have much opportunity to see thyroid cases. Attempts must be made to ensure that all students and trainees are exposed to the key thyroid diseases, wherever possible throughout the period of training. This requires training students and residents in community settings. Medical education is moving rapidly to increase the amount of student training in ambulatory care and community settings.

All students and trainees should be exposed to new cases of hyperthyroidism, Graves' disease, hypothyroidism and should have the opportunity to examine thyroid glands with nodules or goiters. These are the prototype cases, exposure to which in training will enable them, when in practice, to diagnose any thyroid condition more easily.

The two most important factors that lead to deep learning are:

• Learning that takes place actively rather than passively; that is, students learn by themselves rather than simply being told by a teacher.
• An opportunity to apply what they have learned as soon as possible after the learning has taken place.

This means, that after having gained new knowledge and skills regarding thyroid disorders, students should be exposed to patients with thyroid diseases and given the opportunity to assist in their management as soon as possible. If something is learned and no immediate opportunity is given to apply that learning, it is lost. As the popular saying goes, if you don't use it, you lose it.

Increasingly, practicing physicians need to be devoted self-learners. They must be given the resources to seek their own new knowledege and information and given support and encouragement to do so.

The ultimate key to improving practicing physicians' skills in any given area, including that of thyroid diseases, is continual professional development and education. Medical school lasts only a few short years. The practice of medicine is for a lifetime.

Fortunately, Canada has long been in the forefront of providing and supporting continuing education for doctors. As the practice of medicine changes at an ever faster pace, encouragement and support for doctors to maintain their skills and to acquire new ones will become increasingly important. This is true not only in Canada but also worldwide, wherever thyroid disease remains a major problem