Most American, medical students come out of medical school
having passed 2 USMLE’s, accumulated well over 3,000 hours of clinical
experience, evaluated hundreds of patients, and assisted with scores of
procedures. They then enter residency where they are treated as if they know
nothing.
Most of these students slog through medical school rotations
and later residency, picking up pearls along the way. With these pearls,
they stitch together what will eventually become their way of
practicing. They do this under the watchful eyes of attending physicians who often
bemoan of how the younger generation does not get “it”. No one ever defines
what “it” is. Few of these attending physicians remember that their own
teachers also said the exact same thing about them.
I will not pretend to know all aspects and permutations of
“it”. However, sometimes “it” is the lack of a framework with which to
understand the information and experiences that the student is thrown into.
A framework in this case is a mental structure that gives
the student direction, a guiding principle (or set of principles) for how to
make their knowledge function in real life. With a lot of experience, most
physicians gain these mental frameworks in a mass-volume, brute-force
kind of way through residency.
However, to make frameworks explicit from the outset
is a powerful tool in maximizing learning from clinical experience.
For example, in emergency medicine:
You can tell a trainee,
“Go see a
patient and present their case to me”.
Alternatively, you can give them a
framework that can guide them,
“Think of the 3 most dangerous conditions
your patient could have. Make sure they do not have any of them.”
With the second, the trainee has guiding principles to help focus
their efforts. Despite being broadly worded, the second method gives a
direction that can guide the trainee’s actions.
You could put more detail into this framework if you thought
your trainee needed more explicit direction.
Building on our previous example,
“Find
out what the patient’s real chief complaint is. Determine if they have any of
the 3 most emergent conditions for their chief complaint. Present their case to
me with a plan that focuses on what diagnostics and therapeutics you want to
do. Be prepared to explain why we are doing each point in your plan.”
With a little reflection, a teacher in any other specialty
could give equivalent types of frameworks to their trainees.
When they have a good framework, the trainees’ attention and
efforts focus on the important aspects of a patient’s case. Trainees that do
this learn more from each patient interaction, grow more quickly as clinicians,
grasp advanced lessons in patient care more quickly, and can take better care
of their patients.
So clinical teachers, please consider what frameworks you
might use with your trainees to maximize their learning. Give your trainees the
guiding concepts that will focus their efforts and help them grow faster as clinicians.
If you’re interested in learning more about using cognitive
frameworks to help your trainees, please consider checking out my book: A
Guide to Clinical Decision Making
