Common Things Are Common
Kendra Campbell -- There’s a famous saying in medicine that common things are common. This is a rather obvious statement, but is so very true nonetheless. Seven weeks into my surgery rotation, I can completely confirm this observation. Today on consult, I saw three patients with appendicitis, two with cholecystitis, one with pancreatitis, and one with gastritis. For general surgeons, these patients are the bread and butter of their practices. And just as the textbooks would have me believe, the appendicitis patients were all young males. The cholecystitis patients were fat, female and forty. The pancreatitis patient was an elderly alcoholic male. The gastritis patient was a stressed out, heavy drinker who abused NSAIDs.
Today’s patients represented about 85% of the patients I see every day. Throw in some hernias and DVTs, and you have the gist of my experience with general surgery. It really got me thinking about the curricula in medical school. It seems that 90% or so of what we learn in med school is about obscure diseases. We learn about Pompe’s disease, Klinefelter syndrome, and Creutzfeldt-Jakob disease, but how often do we come across patients with these pathologies? Sure, they do happen, and we need to be prepared for their presentations, but should we be spending over 90% of our time learning about them? We barely covered topics like pancreatitis and cholecystitis, but this is what we see every day.
I’m really not sure what the solution is. Physicians need to be well versed in most diseases and pathologies, but how much time should be spent covering these topics? Might our time not be better spent going over common maladies, their presentations, and their treatment?
I think one of the reasons that we have to cover all diseases is because by understanding their pathophysiological processes, we are better able to understand and appreciate normal anatomy and function. Learning about how the body can be attacked or go awry helps us to truly understand how the body works. And then maybe we are better able to understand and treat the common diseases that we see.
I’m not the first person to bring up this topic, and I certainly won’t be the last. Many people have discussed various changes that need to be made to the med school curricula. Should we really force pre-med students to take organic chemistry? Should we make students planning on going into psychiatry memorize obscure dermatological diseases? I don’t have a good answer.
Perhaps it makes sense to focus on everything that can possibly go wrong during our pre-clinical years, but then hone in on the more common diseases during our clinical years. For me, it seems like this is how things have been going thus far.
Another famous saying in medicine is that if you hear hoofbeats, think “horse,” not “zebra.” But the reality is that one day we might have a zebra walk in to the hospital, and we could make a grave error if we call it a horse. But for now, I guess I will continue to see and treat the horses, while trying to keep my eyes peeled for the black and white stripes.
You predicted my response:
"But the reality is that one day we might have a zebra walk in to the hospital, and we could make a grave error if we call it a horse."
Like the 83rd time I did a fundascopic exam and saw papilledema.
Posted by: thomas | Oct 6, 2008 8:49:27 AM
Yes, i agree with your observation that medical students and eventually doctors in north america are exposed to common pathologies of NORTH AMERICA e.g. flu on one extreme and AIDS on the other. They lack first hand experience on pathologies of the thirld tropical world for example all the parasitic diseases of Africa and their symptoms....sleeping sickness, skin and visceral Leishaniasis, malaria. One crazy suggestion yet effective would be to rotate students from the US/Carib and whoever is willing to pickup the cost in medical centers (build by and operated to the standards of the west). One center will be say in South Africa, another in Japan and a third in Europe. These centers will expose future doctors to diseases that they would have only seen in text books.
With that said, someone will argue that by saying why bother training someone who will never see these diseases except if he/she moved and practice at those locations....valid point!
Posted by: George | Oct 7, 2008 9:30:33 AM
Absolutely every medical student should have organic chemistry under their belt. Same goes for physics and calculus. No one seems to doubt the need to study human physiology in medical school, so I don't understand why people whine about having to learn fundamental basic science. How is pharmacology to be understood at all without organic chemistry?
Kendra, it's exactly this kind of thinking that has made some schools consider getting rid of gross dissection altogether. It's the same kind of thinking that has taken away microscopy from the pathology and microbiology courses we must take, two areas which I doubt anyone would dispute are essential to medical education.
I know it seems silly to 'learn all this stuff we won't have to know'. How exactly do you know at this point, still a medical student, what you will and won't have to know? I can see how you'd think that, when every one has one of those hand-held PDAs, computers at reach and endless protocols, decision-trees and rationales that tell us what to do given a certain algorithm. They have the procedures and indications all written out for us. But wait. Any monkey could do that: follow a procedure or a protocol.
And I'd like to also commend George's comment and add that your post is remarkably American-centric, where people die from mostly diseases of luxury, and of course, AIDS. Here we have diagnostics to help us when clinical diagnoses and judgment fail. The rest of the world, the majority of the world, is not like America. Open your eyes.
I bet 90% of the words most people use every day are the same exact words, and you could fit them all on a page or two. So why bother reading or learning vocabulary any further than that?
Posted by: Sharon Wu | Oct 7, 2008 2:57:00 PM
Yes it is important to study all those basic sciences and the obscure diseases because like everyone says "you never know" but i think you adress a topic that is often overlooked when debating medical education, do we spend enough time teaching how to diagnose and treat the obvious everyday diseases. one may argue that is what residency is for, then why when we do enter residency we are expected to know these obvious diseases and diagnosis and often times get reprimanded when our knowledge is lacking? should we keep medical education the way it is, or strive to reform and improve it so that future generations would benefit?
Posted by: Intern | Oct 8, 2008 8:31:06 AM
A very valid commentary; the one thing that medical students learn as they go into their clinical years is the actual "incidence" of one disease versus another. I had a fresh new 3rd year medical student rotate with me in clinic on what apparently turned out to be "allergic rhinitis" day. After about the fourth AR case I turned to my student and told her I was sorry that the clinic was turning out to be quite routine and mundane. To my surprise she turned to me and said, "Oh no! This is great. Actually all throughout med school we never learned how to diagnose and treat these things." Thinking back to my med school days, certainly most of the pathology I treat everyday I learned about in my clinical clerkships and not in my 1st and 2nd year didactics. Indeed, a 25 year old coming in with cough and blood-streaked sputum is much more likely to have a viral bronchitis than Wegener's granulomatosis. It is definitely important to have an adequate differential diagnosis when evaluating a patient, but you first really need to put the patient in context with the situation, location, and demographic. You may feel like a superstar by coming up with a 50 item differential list, but when you are seeing a patient every fifteen minutes in your office, you better narrow down your list to common things first or else you will never be able to pay your light bill!!
Posted by: FM resident | Oct 14, 2008 4:17:47 PM
"How is pharmacology to be understood at all without organic chemistry?"
C'mon Sharon, you can't be serious. Organic Chem has absolutely nothing to do with the study of the systemic effects of drugs. Also Calculus is not too important, Statistics yes but not Partial Fractions and 5 by 5 Matrix.
The medical curriculum is overbloated and most times students lose focus and study minute details without an understanding of the more common diseases and topics. There is need to review the medical curriculum in a lot of countries.
Posted by: Kene | Oct 15, 2008 2:31:22 PM
What i feel is that we should always know the commonest at our fingertips as that's what we will be seeing in the wards however still bear in mind as much as possible the uncommon ones with similar presentations..Definitely right Kene, medical curriculum review is needed for most countries..
Posted by: missy | Oct 17, 2008 1:57:16 AM
Could you run that by me again?I've gotta catch the bus
Posted by: Supra Skate | Nov 2, 2010 7:01:53 PM
Please give my regards to your family
Posted by: Supra Vega | Nov 2, 2010 10:56:30 PM
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