Graduation date TBD

Over the past several weeks, I have been studying for re-certification with the American Board of Pediatrics.

It is every bit as super-fun as you would imagine.

The method I used to study for the board exam last time was to do a ton of practice questions.  Indeed, the American Academy of Pediatrics (not the same as the ABP!) publishes a set of practice questions every year, which one can purchase for a reasonable fee.  God willing and my small children consenting, I will get through two years’ worth of questions before I sit for my exam in a few weeks.

The set of questions I tackled last night included one about the management of a yeast infection on an indwelling venous catheter in a patient in the neonatal intensive care unit.  Test-takers were asked the pick the most appropriate anti-fungal medication for the patient’s infection.  I am pleased to report that I got the question right employing a “pick the answer you’ve heard of” strategy.  Sadly, the strategy is not 100% effective, and is wholly worthless when you have heard of none of the answer choices.

Now, the chances that I will ever be called upon to manage a central line infection for a patient in the NICU are fleetingly small.  Should that ever come to pass, something has gone Seriously Wrong somewhere.  The people who should be making that call are neonatologists, and I am perfectly happy to never ever make management decisions along those lines, just as I’m relatively confident that your average neonatologist would be pleased as punch to get a lifetime exemption from ever having to diagnose ADHD or pelvic inflammatory disease.

The American Board of Pediatrics does not care.  Its apparent goal is to ensure that, in the event of a zombie apocalypse in which I am the sole pediatrician survivor, I will be able to manage an intensely ill neonate’s central line yeast infection while also prescribing chemotherapy for osteosarcoma and ascertaining if a preschooler’s stutter is developmentally normal.  Drop me onto a desert island with a tongue depressor, an electron microscope and a can-do attitude, and I’ll take on any syndrome, malady or injury the kids there can throw at me.

That seems to be the thinking, in any case.

All of this sprung to my mind as I read this essay at WBUR’s Cognoscenti blog about the length of medical education.

[M]edical school education is actually much more variable. Most schools keep students in the classroom for two years, and in clinical sites for another two. Some, however, compress and rearrange material, creating unique requirements. As a result, some learners gain broad exposure to clinical areas while others receive almost none. Some trade clinical electives for research or international experience. Many have extended periods of free time. None graduate with the exact same expertise or experience.

I actually went to a non-traditional medical school that combined undergraduate and medical studies into six years.  It was not without its flaws (believe me), but one area where it was very strong was in the clinical skills it developed.  I actually had a full three years of clinical rotations, which is more than you will get in almost any traditional four-year school.  I got a lot of very hands-on patient care experience.

But no matter how many years of clinical experience I got in medical school, nothing really can mitigate the challenges that come with being a competent practicing physician over time.  When I was graduating from medical school, HIV was only just becoming a chronically-manageable illness through the advent of HAART regimens.  The overwhelming majority of AIDS patients I managed could expect to die of their disease within the span of a few years, which is (mirabile dictu) not at all the case now.

[T]ailored training marks every profession — except that the body of medical knowledge continues to grow exponentially. This is partially because biomedical science is generating discoveries more rapidly than ever before. Between advances in areas like genetics, radiology, and biomaterials, modern doctors must know far more than their predecessors.

This is undoubtedly true.  Even in the relatively short period of time since I finished my fellowship, things have changed significantly.  Much of what I learned in my training as a subspecialist in adolescent medicine dealt with managing abnormal Pap smears.  That information has been rendered almost entirely obsolete thanks to the HPV vaccine and new clinical guidelines.  Expertise I developed over three long years, gone the way of the dodo in less than a decade.

As I said, I went to a medical school that offered a full additional year of clinical rotations compared to the norm.  I think that added year was a real asset.  But whatever advantage it conferred has long since been swept away by ever-more-rapid discoveries, revisions and advances.  As a resident I occasionally prescribed medications that, if I see them prescribed today, serve as a marker of a provider who doesn’t know what he’s doing.

Medical school should be as long as necessary to have every student rotate through core specialties to determine which she wants to pursue, and preferably a handful of electives to deepen her knowledge and round out her education.  It should provide enough time to give graduates a firm grasp of the anatomy and physiology of the human body.  And that’s about it.

What every graduate should know as he grips his diploma, however, is that he’d better be used to studying.  My fellow residents and I would roll our eyes at the crusty old community pediatricians who’d admit their patients to our hospital and whose clinical skills had long ago calcified into outmoded forms.  What I didn’t fully appreciate is how rapidly that process can happen.  Every brand new doctor should realize that all too quickly his hard-earned body of knowledge can become the professional equivalent of two vast and trunkless legs of stone.

But enough of this.  I should be studying.