Hacker News Reader

Comment by BucketSort | Hacker News Reader

Med school -> Memorization school. The medical profession needs to figure out how to use technology more effectively in its processes. I'm convinced that having doctors spend years doing route memorization hinders their critical thinking. It also puts a ton of stress on medical students who have to spend an exorbitant amount of time drilling. Of course, that would harm the medical industrial complex, so we must make being a doctor as difficult as possible.

View on HN

You have to build the background knowledge to even be able to speak the language of medicine. This is not difficult "just because", it's difficult because it's a huge amount of baseline knowledge that must be assimilated, before you can even begin to think critically.

This is like telling someone "we need to figure out how to use technology to prevent people from spending years of rote memorization before they can speak <X_foreign_language>!"

The problem with that analogy is Med school treats medicine like speaking English. But you can simplify the material and treat it like teaching a constructed language.

For example if you named the bones in the fingers as left, thumb, two then it’s little effort to recall. Instead people need to recal the stuff like distal phalanges. Math is arguably worse with redundant notations for the same thing. So, I see the benifit of avoiding creating multiple systems.

I don't think that's a good example. There are only 206 bones in the adult human body. It doesn't take very long to memorize those. The real memorization time is spent on other stuff for which we don't even have common English names. You could invent new, simpler names for every anatomical part, every disease, every symptom, but that would be a huge undertaking and would only make memorization marginally easier.

Yeah the idea is skip names as the foundation altogether. Instead characterize the spaces by their properties and symmetries, and when there's an exact number of things (like bones) use a GUI (body diagram, decision tree) to air recall so people can just learn the names on the job.

>so people can just learn the names on the job

Ah, yes, the best way to learn all the intricacies of a human: osmosis.

Good luck attaining knowledge that takes 8+ years of focused study in medical training today through osmosis over 30 years of "on the job" training, being paid $0 because you are still "learning" and can't contribute to anyone's actual medical care during that time unlike a resident physician.

My point is if some of med school is obvious cruft that can be removed and or altered to be more useful in practice. Why not?

PS: I would include tendons, joints, and muscles etc not just 206 bones in that example. Also, that was rather off the cuff as left/right could confuse things so maybe you want port vs starboard or something.

You’re really displaying your total ignorance of medicine now - our anatomical naming conventions are highly specific. Anterior, superior, distal, medial, ... hell, even phalanx means finger. Your lack of knowledge is causing you to make very general assumptions about the teaching and learning of medicine that are incorrect

Phalanx does not mean finger to most people until they start learning medicine. It’s cruft.

Phalanx also means finger to most students of history. It is, after all, Greek for Finger (secondary to Aristotle dubbing the bones so).

What's your point? It seems to be that medical terminology (or the expert body of knowledge that distinguishes someone with anatomical or medical knowledge from the layperson) is an artificial construct which imposes undue restrictions on the easy transfer of this knowledge - guild behaviour.

Every realm of knowledge has its own language which must be learned in order to be proficient. In briefly reading your other replies in this thread, it seems like you feel that computing and programming don't have these restrictions - that is absolutely not true, just ask anyone who has been trying to learn programming themselves but is stuck on the difference between a method and a function (only to find out they are the same thing).

It is not possible to be an expert without gathering the knowledge, the language, and the real understanding necessary to partake in the field. Anything else is simple arrogance, to assume that any specialised field that people spend decades learning, is actually just arcane crud and cruft that disguises the simplicity hidden within

I think you’re getting the wrong impression. I find medical papers tend to be easier to read as a non specialist than recent matimatics papers.

Math however is trying to be as clear as possible and more elegant notation generally though not always wins over time. Mathematics don’t still use Roman Numerals even though they worked.

PS: Languages change over time, programmers dropped the term subroutine. This can look messy, but it’s benifical over time.

I may be getting the wrong impression - but what is the point you’re trying to make - and did you just choose a shitty example? The left, thumb, Two, carries so many problems - do you mean palmar or volar surface? Medial or lateral? I can accurately discribe a lesion at the base of the left thenar eminence and everyone who has studied anatomy anywhere in the world will understand the exact part of the body I am talking about. In another more specific example, I might describe petechial haemorrhages proximal to the iliocaecal valve. These words aren’t in common usage but again, every medically trained human in the world would know exactly what I am describing.

I understand your last comment about languages changing over time (technical languages) - medicine is no different. See for instance the Dukes grading of bowel cancer, now largely superceeded by TNM Grading which carries specific histological and pathological meanings (as dukes does) but is applicable to all cancers.

All fields have jargon, but math culture is at least "up to isomorphism".

Although I would welcome the use of common names instead of Latin names, the names in anatomy and pathology are annoying but not a hindrance. The difficult thing is to remember causes and symptoms of diseases, innervation of muscles, drug pathways, etc. That would be hard to simplify.

Instead of Latin/Greek root words, you'd have to learn a new system of common words. And not just new trainees, but also practicing physicians, because everyone has to speak the same language.

They did what you suggested.

“Distal phalanges” are the far away phalanges, which are the bones that are in an array like a phalanx in the extremities.

The problem is that language changed after that, and the expectation for those words to make intuitive sense changed in the broader culture doctors were pulled from.

They’re then faced with having to rename everything, breaking with the established record and creating confusion or having to explicitly teach the names.

I’m also curious what you think is redundant in math notation.

https://en.m.wikipedia.org/wiki/Notation_for_differentiation

Taking classes that use different notation for the same thing is annoying.

Your example is not analogous to medicine - there is consistent and highly specific naming conventions for a reason

It’s not generally ambiguous in math, and a similar situation exists when a patient describes his symptoms using different words.

That said, I started with: ‘Math is arguably worse with redundant notations for the same thing.’

He asked “I’m also curious what you think is redundant in math notation.”

You can undoubtedly put priority of grammar over vocabulary, no? You are not thinking in terms of systems that allow us to find the "words" we need after being guided by our mastery of the grammar and ability to reason about what must be said given a situation. I think what you said is valid only if we think about speaking a language unassisted by these types of systems, which is exactly what I feel must be left behind.

Edit:

Also, this is what happens in practice anyway! Doctors don't remember a lot and constantly have to look things up ( as is understandable and expected ). You must be a master of the "grammar of medicine" though. Otherwise you won't be able to construct well formed sentences... aka medical thoughts.

You need some memorization to give some concrete instances of the grammar, of course; however, going overboard on the "vocabulary" is not constructive and shifts the focus onto knowing a lot of words, not knowing how to construct great sentences. It's like a writer that knows a lot of uncommon words, but ends up having nothing meaningful to say... because the power of writing is not in the vocabulary alone, but in the craft of composition.

> Doctors don't remember a lot and constantly have to look things up ( as is understandable and expected ).

They don't bootstrap this search every time. Enough of the basics have been instilled that they will know what they should look up.

You fail to appreciate that there is quite a bit of skills development and problem solving training. The first two years are more memorization heavy, as you have to learn the language and basics. Years 3 and 4 are more focused on navigating the health care system, interacting with patients, performing technical skills, physical examination, use of imaging, diagnosis, etc. Memorization is only a fraction of what you do to become a competent physician.

I take this as:

1,2: memorize 3,4, residency: poorly compensated labor

Medical school is 4 years, pre-medical school is 4 years, internship is 1 year, residency is 2-7 years.

Is that contradictory to what I wrote? Also note that EU combines premed and med school into <8 year bachelor degree.

First two years of medical school are in classroom, second two years are clinical rotations.

Residency is after medical school, and that's the first time you start earning a meager paycheck. In medical school, even when you're "working" with patients, you still pay tuition.

Yeah exactly. And at the very least an EU 6 year med bachelor model would pay you something for years 7 and 8 (counting feom high school).

> The medical profession needs to figure out how to use technology more effectively in its processes.

Med students are probably the most numerous users of spaced repetition tools like Anki. The rest of us are doing it the inefficient way.

Good tool wrong objective! OP means use technology to skip up-front memorization.

How do you acquire knowledge without memorization?

What technology do you anticipate using? Johnny Mnemonic neural implantation?

All learning requires some memorization. That doesn't mean all memorization is equally good. Memorize that which is hard to look up. And compress what you need to memorize as much as possible; the compression process itself is intimical to understanding and generalizing.

Medical school today would be like learning programming by memorizing the x86 ISA spec.

The x86 ISA spec is a doddle compared to organic chemistry.

Which is a pre-med subject.

There is a minimum amount of material in any subject that needs to be available for rapid recall in order to be an expert in that subject.

A wide variety of different areas have been studied to relate performance to level of learned information. Linguistic fluency requires easy recall of vocabulary. High rankings in chess depend on the recognition of thousands of distinct patterns. Musical improvisation requires thousands of hours of tedious repetition and practice. Effective programming requires a body of knowledge encompassing a variety of topics, a lot of which will be memorised as a side-effect of repeated exposure.

But if you think you can be a better doctor than a doctor by scanning the indices of medical textbooks -- realising a little late that you are unfamiliar with a lot of the terms and also unsure in what order the concepts need to be assimilated before you can apply them -- then at least make sure your will is up to date.

Orgo is exactly what I'm talking about. Whether or not it's harder or easier is besides the point: it's simply too low a level to be useful.

I'm all for a liberal arts approach of understanding other layers of abstraction for more context, but empirically this is not how the vast majority of premeds experience the orgo requirement. And if liberal arts was really the goal, then corresponding amounts of public health classes would also be required (layers of abstraction above and below at equal distance). But that's not the case. Clearly then it's not about a broader perspective but instead about weeding people out arbitrarily for sake of some combination of wages and egos.

I'm not a doctor or on that track. But I am a musician and programmer, at say 1000+ hours for the former, and 10,000s of hours for the latter. Not once have I engaged in flash-card-style rote memorization for either, especially not for any written test. I am certainly full of random facts by now, but the knowledge I hold most valuable is not that which I could also get from API docs or stack overflow.

No doctor, med student, or premed I have ever met studdied their field remotely like the ways I've studdied mine. Is being a doctor inherently that different? I can't see why not, and if I look at economics and public health research the arguments I give leap out at me.

(I also studdied Chinese for a few years when I was younger and definitely did not do enough flash cards. Now that is a field (language learning) where rote memorization is inherent to the problem at hand.)

> OP means use technology to skip up-front memorization.

I would greatly prefer my doctors to not skip up-front memorization.

If my prescription required citations, my tested data, the doctor's conjectures (because most conditions cannot be diagnosised with much certainty yet), and formal reasoning to connect it all, I couldn't care less.

(Before somebody complains of layman mob rule, remember checking a proof vs inventing a proof does and should require far less expertise.)

Also, let's be real, the type of cramming these students have to do is antithetical to long term retention. Most of the knowledge is still greatly reinforced in the job. Cramming for the test is a "first draft" for the rest of one's career, just as taking notes in lecture (also a bad idea btw) is first draft for preparing for the test.

Cramming isn't spaced repetition.

I would have thought that name "spaced repetition" explains why.

> The medical profession needs to figure out how to use technology more effectively in its processes.

My wife is in med school. It has nothing to do with technology.

It comes down to an insane risk aversion present throughout all of medicine. If you can't prove an alternative method is empirically better, it won't even get tried. If it's not tried, you can't get the numbers.

Even when things are obvious improvements or carry limited down-sides, the whole medical field is hesitant to pursue them.

I think the main failure to use technology is actually in communication, specifically in handoffs, communication with patients, etc. Paper records exist even though the infrastructure to make paper records work (including a population of young people willing and able to make this system run) is largely gone. Practices need to write referrals, and will try to fax documents over which then need to be re-entered. HIPPA, rather than encouraging EMR systems, makes professionals skittish to put anything into a computer. Rather than medical information breeches, we suffer from the medical information not getting to the right people.

You can't really get around the drilling. Medicine is fundamentally different than programming in this regard. You have to know the names, not just the concepts, and there are a TON of names.

There IS technology that does help with memorization. Many, many students use Anki for spaced repetition. Most subscription study sources offer some kind of spaced rep (USMLERx Flash Facts, Firecracker, etc). There is also Sketchy and Picmonics for pictorial memorization of microbes and drugs.

You can't get around the drilling in anything, but the point is that students do an OBSCENE amount of it, and forget most of it. Also, as other's have said, most material is totally irrelevant to the actual practice of medicine and will be forgotten quickly. EX: You don't need to know organic chemistry to be anything but a medical researcher (which should be a distinct profession), yet the system falsely increases the number of requirements to keep people in school longer and maintain control. It's a corrupt system In my eyes, and people fall for this bullshit that it's so difficult to be a practicing doctor... it only is when you add extraneous stuff that is not necessary in the practice of medicine.

Most doctors aren't researchers. You don't need that much education to practice medicine and fit the role of what people need when they seek a doctor. It has to change, because the current state of affairs is out of control. People are losing all that they have to the raping of the medical industry.

Yet another person with no experience in medicine, finally figured out how to "disrupt" medicine with technology.

You can't practice medicine without knowledge. You can't learn how to practice medicine without knowledge.

What knowledge is required?

Physics,

inorganic chemistry,

organic chemistry,

mathematics,

microbiology,

cellular biology,

biochemical biology,

molecular biology,

developmental biology,

physiology,

pathophysiology,

human anatomy,

pharmacology,

histology,

gross pathology,

statistical analysis,

internal medicine,

paediatric medicine,

general surgery,

orthopedic surgery,

neurologic surgery,

urologic surgery,

gynecology,

obstetrics,

outpatient medicine,

cardiology,

pulmonology,

nephrology,

hepatology,

radiology,

neurology,

psychiatry,

critical care,

healthcare economics,

medical ethics, et cetera.

If you don't have a knowledge base, you simply can not practice medicine because you don't understand how things actually work...

Critical thinking without knowledge isn't critical thinking, it's ignorance.

How does the brain work?

Okay, that was sarcastic. But in my view no doctor knows all of those subjects in depth. Pre-med students take the basic STEM courses in order to pass their MCAT's, and then forget most of what they learned, and those courses were all just superficial intro courses anyway.

To be fair, the same can be said of most engineers.

Many med students (wisely) major in a STEM subject, so they may get into more depth than someone who majored in some kind of "studies." But what they know is a function of what they actually studied, learned, and kept up with after college, which does not make me super optimistic.

Since you haven't been through medical education and training, you wouldn't understand that while certain details are forgotten, the core knowledge that serves as the basis for further learning is retained.

Do you remember every detail of your first grade education? Probably not, but it has served as a foundation for everything else you learned in life. How do you learn calculus if you don't learn numbers and letters?

>If you don't have a knowledge base, you simply can not practice medicine because you don't understand how things actually work...

Nonsense. Why does a heart surgeon need to know anything about psychiatry? What does a radiologist need to know about cellular biology?

The equivalent for programming would be forcing someone to understand how transistors work at the atomic level, CPU architecture, and OS structure before letting them write a webapp. It's definitely one of the problems in medicine. There's way too much useless knowledge required leading to a limited supply of people being able and willing to master it. Plus, it makes it much more expensive and time consuming to train all of those people.

As a radiologist, I have to know a lot about cellular biology to understand and predict the imaging manifestations of cellular disease.

You can’t just delete the baseline foundational knowledge.

>As a radiologist, I have to know a lot about cellular biology to understand and predict the imaging manifestations of cellular disease.

A given radiologist shouldn't be predicting the imaging manifestation of cellular disease. They should be using their knowledge of how known diseases or conditions appear on scans to diagnose the issue. The people that need to understand things on a deeper level are the ones trying to devise new tests or scans to expand front line radiologists diagnostic abilities.

It's pretty wild you're telling a practicing radiologist how they should be doing their job.

One of the problems with letting people in a profession set the requirements for that profession is that they exaggerate them to limit competition and increase their earnings. You end up with things like radiologists saying they need to know cellular biology. It's simply ludicrous on its face.

Radiology is a particularly egregious case. If it weren't for legal protection the profession would be dramatically different. It's obviously stupid to spend a bunch of time training them to interpret and diagnosis a bunch of different scans. Basic efficiency would be to train Person A to interpret chest X-Rays, person B to do CT scans, Person C for leg X-rays and have them spend all day doing that one thing. Instead, radiologists spend a decade learning how to interpret a hundred different things and spend 1/100 of their time on each of them.

How do you interpret an image if you don't have an understanding of what is in it?

In other words, let's say that a patient has a fever. Chest X-ray was done.

High-school educated "radiologist" sees the image. Does he understand the anatomy? The variations of anatomy? Pathological manifestations of potential causes of fever? How to exclude image artifact versus include potential sign of pathology? What about findings that are not related to fever but need to be identified, further characterised and further imaging required for follow-up? What about signs of infectious fluid versus non-infectious fluid like blood or extravasated fluid?

What about when the ordering physician wants to discuss the findings with the "radiologist"? Will that "radiologist" actually understand anything that the physician is talking about?

There is a role for AI assisting in rapid analysis of radiological studies, however radiologists can never be replaced because AI will never perform to the level of or have the same functions as a physician radiologist.

>How do you interpret an image if you don't have an understanding of what is in it?

Because you're looking to identify patterns and match them to known ones. To use an analogy, I can teach you to identify statues of Hindu Gods without teaching you anything about Hinduism. For example, to identify Ganesh you need to know that he has an elephant head. Knowing that he has an elephant head because Shiva cut his human head off doesn't really help you.

>In other words, let's say that a patient has a fever. Chest X-ray was done.

>High-school educated "radiologist" sees the image. Does he understand the anatomy? The variations of anatomy? Pathological manifestations of potential causes of fever? How to exclude image artifact versus include potential sign of pathology? What about findings that are not related to fever but need to be identified, further characterised and further imaging required for follow-up? What about signs of infectious fluid versus non-infectious fluid like blood or extravasated fluid?

All of the things you mentioned are things that a radiologist interpreting a chest X-ray needs to know. What you need to explain is why someone interpreting a chest X-ray needs to understand Organic Chemistry. And the vein structure of the leg. And the typical development pattern of a child. And the various mental illnesses a person might have. And interpret a knee MRI.

>There is a role for AI assisting in rapid analysis of radiological studies, however radiologists can never be replaced because AI will never perform to the level of or have the same functions as a physician radiologist.

No, but I could easily take 10 people, train them each 1/10th of what a radiologist studies, and have them perform just as well as 10 radiologists by routing the right stuff to the right person.

The average Radiologist does not only interpret a single modality or the same body part day in and day out (Radiograph, CT, MR, ultrasound, nuclear scintigraphy, PET, or mammography). We are prepared by our extensive residency to competently read any and all of these upon graduation. We do not interpret these in isolation; we are constantly comparing to prior studies across modalities, often across overlapping body regions. I completely disagree that barely trained hyperspecialists would be sufficient.

While specialization is coming to all of Medicine, we tend to cluster by body region/disease state, rather than by modality. This is because all of the modalities provide complementary information and you must be able to cross reference across the various manifestations of disease.

All of medical knowledge is iterative. Unlike programming, you can’t just abstract the low-level programming. The premedical curriculum provides the baseline knowledge to understand pharmacology, which is essential when trying to understand our interventions in physiology and pathophysiology. We need to know both physiology and pathophys when interpreting imaging to know how disease manifests and what is abnormal versus post therapy related change.

We have to know how referring clinicians will treat disease, and know the major complications to look out for on imaging. We discuss their treatment plans during tumor boards and need to speak the language of the treating teams so we can tailor our interpretations to be useful.

There are no easy shortcuts here. NPs and PAs are a living experiment at a shortcut, but what I see day in and day out is that the people they consult (radiology and pathology) need to know even more clinical medicine to help the inexperienced NP or PA in knowing what to do when something happens that deviates from the protocol. Many many many times I will call with a semi-urgent unexpected finding, and just get silence on the other end of the phone. They don’t know what to do, whereas on weekends or nights when I get residents or attendings, I don’t hear this complete absence of understanding.

> I completely disagree that barely trained hyperspecialists would be sufficient.

>While specialization is coming to all of Medicine, we tend to cluster by body region/disease state, rather than by modality.

These are contradictory statements. If Doctors typically go:

No Training -> Trained in everything -> Specialized in body region/disease state

You can easily go:

No Training -> Trained in body region/disease state -> Specialized in body region/disease state

So even if we assume it's not possible to specialize radiologists any further than they already are we can still cut the training time and difficulty.

>We have to know how referring clinicians will treat disease, and know the major complications to look out for on imaging. We discuss their treatment plans during tumor boards and need to speak the language of the treating teams so we can tailor our interpretations to be useful. We need to know both physiology and pathophys when interpreting imaging to know how disease manifests and what is abnormal versus post therapy related change.

No one is denying that there are things in medicine that are complicated and require very skilled people. What you describe is the end state of a fully educated and experienced doctor. Medicine is more or less the only field that makes you become that before you start working. Can you take a reasonably smart person off the street and have him designing plans to treat tumors in a year? No. Can you take that person and train them to identify normal appearing lungs vs cancerous ones in that time? Probably. And can that person learn on the job and develop the ability to design a treatment plan over the course of 10 years working? For sure. And they wouldn't learn everything taught in Med school. They would pick up only the things relevant to the job they are trying to perform.

>All of medical knowledge is iterative. Unlike programming, you can’t just abstract the low-level programming. The premedical curriculum provides the baseline knowledge to understand pharmacology, which is essential when trying to understand our interventions in physiology and pathophysiology. We need to know both physiology and pathophys when interpreting imaging to know how disease manifests and what is abnormal versus post therapy related change.

Going back to the comment that kicked this all off. If I handed you a cellular biology final from Med school do you think you'd be able to pass it? What about the USMLE?

>There are no easy shortcuts here. NPs and PAs are a living experiment at a shortcut, but what I see day in and day out is that the people they consult (radiology and pathology) need to know even more clinical medicine to help the inexperienced NP or PA in knowing what to do when something happens that deviates from the protocol. Many many many times I will call with a semi-urgent unexpected finding, and just get silence on the other end of the phone. They don’t know what to do, whereas on weekends or nights when I get residents or attendings, I don’t hear this complete absence of understanding.

Every other field has the ability to take inexperienced people and make them experienced. There's no reason medicine can't do the same. Your clueless NP and PA should have more experienced people to go to for help when they experience something new. The next time they get that call they wouldn't be as clueless.

What you are describing is literally how medical training works. Residency IS on-the-job training. Medical school provides the foundation to then learn on-the-job; residency transitions them with graded responsibilities to independent practice.

As far as your targeted questions, yes, I do think I would pass a cellular biology test from medical school. I wouldn't get 95%+ but I would expect myself to get at least 80% correct.

I'd estimate the overwhelming majority of practicing physicians would pass the USMLE if they took it cold. They probably wouldn't do as well as they did after many weeks of dedicated study, but they would be above the minimum threshold.

>What you are describing is literally how medical training works. Residency IS on-the-job training. Medical school provides the foundation to then learn on-the-job; residency transitions them with graded responsibilities to independent practice.

It's not because you can't start on the path without going to medical school. And you don't need medical school to start learning radiology. I messed up my elbow in high school. They showed me the x-ray and said this is a fracture, this is a chip, etc. It wasn't difficult to understand and with enough time and practice I'd be able to see them in other x-rays. I don't see where something like Organic Chemistry comes into play.

>As far as your targeted questions, yes, I do think I would pass a cellular biology test from medical school. I wouldn't get 95%+ but I would expect myself to get at least 80% correct.

So ~20% of what you learned in cellular biology isn't needed as a radiologist assuming you only remember what you've actually needed.

There are a thousand reasons why your theories make absolutely no sense at all in the real world. You also make baseless and downright false assumptions due to your complete ignorance. People like you are part of the issues that make the job harder than it should be. Maybe you could take a break and re evaluate whether you have the elements to make judgement calls? Or enter med school and see if your theories hold water?

You “could” teach a high school student all aspects of medicine, but it’s going to take so long for them to build the groundwork that by the time they can meaningfully contribute, you’d never make the return on investment. This is actually how medical training was done in the years prior to the Flexner report.

From what I can tell in this exchange is that you have an innate distrust of credentialing, because you think because there is some excess therefore the entire system is wasteful. I’d argue that this is the DunningKruger effect in action.

And claiming that 20% of cellular bio is unnecessary is a silly metric when in the US 70% is passing... I don’t think that logical conclusion applies.

Yes we have more tools to look up information that we have forgotten, but as another poster here says “we aren’t bootstrapping the search each time”. If there’s something we’ve forgotten, it’s much more effective knowing where to start the search.

I agree there’s a lot wrong with our current training paradigm; the cost of medical school education is #1 with several terrible downstream effects.

However, there are no shortcuts. You have to put in the time to master the material, else you are doing your patients a disservice.

>From what I can tell in this exchange is that you have an innate distrust of credentialing, because you think because there is some excess therefore the entire system is wasteful. I’d argue that this is the DunningKruger effect in action.

>And claiming that 20% of cellular bio is unnecessary is a silly metric when in the US 70% is passing... I don’t think that logical conclusion applies.

You're saying that you don't know 20% of cellular biology that they teach in med school. You are a practicing radiologist. Therefore, 20% of the cellular biology they teach is not necessary to be a radiologist.

I have certifications in my field. Developer, Senior Developer, and Lead Developer. If I were to retake the tests, I'd get a 100% on the Developer and Senior one without studying for a minute. Those are good tests. They reflect what you need to know to be effective. The Lead one isn't. I'd probably not pass if I took it today even though I've worked several years as a lead developer since I passed it. So despite actually working in the field and becoming a better developer I'd do worse on the test. That means it is a bad test.

So when you say that the overwhelming majority "wouldn't do as well as they did after many weeks of dedicated study" that makes it a bad test. It means that a good chunk of it is meaningless hoop jumping irrelevant to practicing physicians. A competent practicing physician should breeze through a well designed certification exam.

>I agree there’s a lot wrong with our current training paradigm; the cost of medical school education is #1 with several terrible downstream effects.

>However, there are no shortcuts. You have to put in the time to master the material, else you are doing your patients a disservice.

If someone who wants to be a geriatric doctor skips pediatrics I don't see the disservice. Or take someone like a registered Nurse Midwife. Someone with 20 years experience delivering babies. The only way for them to become competent to prescribe pitocin, antibiotics, or use forceps is 4 years and $200k worth of school? It doesn't pass the smell test.

> It's simply ludicrous on its face.

That's not a meaningful test of correctness.

Many medical practices are organised as you describe (for example, surgeries specialising in nothing but hernias), but medical cases often transcend simple boundaries and a broad amount of understanding is required to detect that boundary violation (such as realising it's not a hernia, or that an organ near the hernia seems to be diseased, or that the patient is going into anaphylactic shock because of a surprise reaction to anaesthetics, or ... or ... or ... or ... ).

> or that the patient is going into anaphylactic shock because of a surprise reaction to anaesthetics, or ... or ... or ... or ... ).

And if I go into anaphylactic shock during my hernia surgery should I be grateful that my surgeon did a Pediatric, OBGYN, Neurology, Psychology, and Oncology rotation? Or that they can draw the Krebs cycle?

The level of aggressive ignorance displayed in comments like this is quite shocking. I'm puzzled as to why engineers and developers think they're qualified to give advice to other professionals in fields where they have no education or experience. What causes that type of hubris?

Knowing about CPU architecture and OS structure helps me to reason about the application code I write. Do I understand those things as much as someone who specializes in them? No of course not. But a certain level of baseline knowledge does have its benefits.

Baseline? Sure. But that's not what med school is. It's the equivalent of a masters level course on a dozen different topics.

Medicine is more complicated than computing.

Is it?

They seem to follow a pretty similar career arc. If you take a typical CS grad they're going to go through a couple years as a junior dev, couple more as a more senior one, and then five years or more in they are ready to be in charge of their own project. That's pretty similar to the intern -> resident -> attending pattern that doctors follow.

Honestly, the biggest difference between having a career in programming and being a doctor is the gate keeping. In programming, you can drop out of high school and 20 years later be an expert in the field. There's a path for talented people to go from junior -> dev -> senior -> lead -> principle -> whatever. There's no path like that in medicine. Sure, as a nurse you can go from LPN -> RN -> NP but that's where it ends. Your only option at that point is to spend 4 years and hundreds of thousands of dollars. And there's really no reason for that.

They’re not directly comparable topics like that. A doctor definitely needs to know more than a computer scientist. But all of medicine compared to all of computer science is not an easy comparison to accurately make, since they’re both such broad topics - in medicine, everything from psychology to pharmocology to genetic engineering - in computer science, everything from transistors to complex mathematics to artificial intelligence safety. They’re both topics that are impossible for one human to understand in entirety, but society requires doctors to know a lot more of medicine.

>Why does a heart surgeon need to know anything about psychiatry?

Heart surgeons have patients with psychiatric problems. And patients are typically on psychiatric medications, which have cardiac side effects.

More broadly, heart surgeons are also general surgeons, and some psychiatry base knowledge is necessary to understand their patients.

Heart surgeons don't have to be psychiatrists, but they need some knowledge in it, which is why it's a 4 week rotation in medical school.

>Heart surgeons have patients with psychiatric problems.

Which they don't treat. That's why we have psychiatrists.

>And patients are typically on psychiatric medications, which have cardiac side effects.

Which is something a cardiologist should know. Knowing which mental illness they treat and how it does that isn't relevant.

> >Heart surgeons have patients with psychiatric problems.

> Which they don't treat. That's why we have psychiatrists.

People with mental illness also have heart problems that need heart surgery. It'd be nice if heart surgeons had a bit of understanding of psychiatry so they can avoid diagnostic overshadowing. This is a significant problem that contributes to the shorted lifespan of people with severe mental illness.

https://meta4rn.com/2018/12/15/shadow/

How to treat heart problems in the mentally ill would be useful training for a cardiologist. How to treat mental illness isn't.

Compliance with medication regimes and followup care can affect outcomes in cardiology, as in other areas. Understanding a patient's psychiatric illness, psychosocial functioning, and other factors can help predict treatment compliance. That in turn may influence the treatment regime the cardiologist recommends.

Medications that are prone to abuse, ones that may be more complex to take, ones that can be dangerous if someone takes too many... all are things the cardiologist should be aware of which takes some basic psychiatric knowledge.

There are few in cardiology, but many physical health meds can definitely create psychiatric side effects. How do you differentiate those from an existing psychiatric illness?

There's a large body of literature that recognizes the links between cardiac care and mental health, resulting in poorer outcomes, increased system utilization and costs, etc. Saying "this is my area, that's yours" exacerbates this problem.

The common theme in these subthreads is that you consider your ignorance as a superior source of knowledge. That since you personally don't know about a thing, the thing doesn't exist.

It's difficult to unhorse a debating partner who refuses to allow any evidence but their own imagination.

You have evidence that cardiologists trained in psychiatry are measurably better than those that aren't?

Just let it go. You are making an apex fool of yourself in the eyes of each and every health professional reading this. It would be strictly impossible for hospitals to function based on your opinions, which is why the supporting data you are calling for does not exist. We don't pretend to program better than you do or demand solid data to support your pet language/paradigm. Have a little understanding of others for a change. You are part of the problem, not the solution. Working on that would be the real improvement.

>It would be strictly impossible for hospitals to function based on your opinions, which is why the supporting data you are calling for does not exist.

Oh nonsense. There's plenty of evidence that lower trained providers are just as effective as doctors.

Midwives are equal or better than doctors:

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD...

No difference between Nurse Practioners and Drs:

https://www.ncbi.nlm.nih.gov/books/NBK384613/

Of course we don't have studies comparing what the equivalent radiologist not because it's strictly impossible for it to happen. But because it's strictly illegal.

There's also evidence that the way doctors are trained isn't the only possible way.

Humanities and social science majors who omitted organic chemistry, physics, and calculus, and did not take the MCAT do just as well as traditional students:

https://journals.lww.com/academicmedicine/Fulltext/2010/0800...

Performance in medical school does not correlate with performance in residency:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951767/

>Just let it go. You are making an apex fool of yourself in the eyes of each and every health professional reading this

Put up or shut up. Where is your evidence based argument that cardiologists who have a psych rotation have measurably better patient out comes than those that don't. Or that a radiologist with more biochem knowledge is a better one?

Well, you clearly don't understand what you are reading. Of course there are improvements to be made. Of course we can take shortcuts. No one denies that. Same as you could bypass your shining CS degree and certifications that you are so proud of and still be a lead developer. But as they say "there is no free lunch". That is what you should be thinking about.

Or does your self-righteousness exclude that 3 professionals telling you you misunderstand could maybe have a point? I certainly earn less than you do and have no MCAT, does that make me more truthful? CRNAs also have to learn a lot about cell biology, is that also useless cruft? Something that is taught in med school is to critically review one's own reasoning!

Forget your petty certitudes and slow down. If there was an easy way to do much better, even the AMA could do nothing to stop it. I certainly don't expect to persuade you and therefore will not take the time to "put up" and brandish more useless Cochrane reviews, but you might consider the remote possibility that you are wrong. And extremely arrogant.

Instead of searching for additional academic papers, I went on to read your comment history. Now I understand better. You are the iconic portrait of the American self-made man/woman! Going on a limb, I'd say you have a high chance of being against universal care, medical abortion and other niceties. So yeah, now I can very confidently say that you are downright nefarious to your country's healthcare system. Not just to MDs. The whole shebang.

Go hide under a rock!

"No, I don't have evidence so let me insult you again"

If you feel insulted although I took great care in staying within what could still be defined as polite if strong disagreement, let me just make clear that your behaviour is par for the course. Let's also just highlight that it's the only time over this whole thread that you do not directly oppose what I'm saying :)

> Nonsense. Why does a heart surgeon need to know anything about psychiatry? What does a radiologist need to know about cellular biology?

Medicine doesn't resemble neatly modulular systems with crisp APIs. A nodding familiarity with distant specialities is required because very frequently a patient cannot be well-treated by a single specialist.

I have a psychiatrist, an endocrinologist and an orthopaedic surgeon. They all take an intense interest in what the others have investigated, diagnosed or treated. More to the point, they have enough overlapping knowledge to profit from their interest.

> The equivalent for programming would be forcing someone to understand how transistors work at the atomic level, CPU architecture, and OS structure before letting them write a webapp.

Webapps don't often come down to distinguishing between conditions which are benign through uncomfortable, disruptive, disabling up to fatal, and besides, our hardware cousins have striven mightily to hide the messiness of reality from us. Medicine doesn't have improvable subject matter to protect it in the same way.

You are way overstating the knowledge of most practicing physicians. You are right that most of them learned about these topics at some point, but have quickly forgotten them. I worked with a pediatrician who works in under privileged areas and conducts public health research and she had forgotten the difference between a diploid and a haploid cell (for anyone not bio savvy this is bio 101) yet she still does a fine job treating patients and understands the problems of the communities she works in.

Different people have different strengths and collaboration is all about enabling others to use their strengths. You do not need to learn most of the things on your list before you can make a positive contribution to medicine. Your list would exclude most physicians from contributing.

Yeah, med school/boards require you to memorize some trivia about some or all of those fields. That doesn't mean such knowledge is clinically useful. By necessity, most of that knowledge will be superficial because there is far too much to cover. The stuff that's useful will be retained, while the rest disappears.

As you conclude with, this is really a social/economic problem mascarading manifesting as a technical one.

The problem is doctors (and lawyers) are the best unionized workers in the country. I'm all for unions, but when a certain group of laborers is much better protected than everyone else, and their work legally distinguished creating extra monopoly power, the asymmetries erase the benefits to society.

1. All the memorization acts as gatekeeping to tighten supply. This is in addition to other explicit quotas.

2. Young post trainees (residents, young associates) do the boring drudgery (and in medicine are under-compensated relative to later). This internally is a hazing ritual, pure and simple. Externally, this is again terrible for productivity. Reducing the drudgery at the top of the food chain removes the psychological yearning for improvement from those with more power. And in the resident case exacerbates the lack of competition which would force change.

The long hours of residents + stigma talked about here also exposes the rank hypocrisy.

My three-year (1977-1980) anesthesiology residency at UCLA Hospital was wonderful. Loved almost every minute, including the all-nighters. And no, I wasn't on antidepressants or stimulants other than occasional coffee.

How long were your shifts?

Final year of residency — schedule as senior resident in the house overnight: Day 1 (weekday): Report for duty at 3 pm, take over from the day team with night call team. Try to send everyone on day team home by 5 pm. Cover hospital and all services for Code Blues; emergency intubations; difficult catheterizations/IVs; patients who arrived late and required pre-op history & physical before next day's surgery; anesthesia for deliveries in OB; anesthesia for cases ongoing from day plus emergencies from ER and in-house. Done at 7 am the next day (Day 2). So 16 hours. No sleep as a rule. Day 2: Off (home to sleep during day to make up for missed night; to bed that night as usual. Day 3: Report for work at 7 am; light duties such as pre-op workups of ambulatory patients; start IVs/arterial lines in pre-op area; Code Blue coverage of hospital and all services. Off at 3 p.m. Day 4: Repeat Day 1. This schedule applied for six months. Note: If Day 1 fell on Saturday or Sunday or a holiday, report to work at 7 am (rather than 3 pm), otherwise identical to weekday. Off at 7 am the next day, so 24 hour shift. Sometimes a nap or two.

And are you aware of all the studies regarding irregular sleep schedules, and humans' inability to judge their own exhaustion and how it affects their behavior?

Great job enjoying such circumstances, but the evidence would point to it being a sub-par way to have residents perform at their best. Surely we could have regular-length shifts (with fixed start times so as to work with a reversed circadian rhythm) and more overlap to solve the patient hand-off problem.

Your hypothesis seems to be that things would improve if doctors were less protected. If you achieve putting that into practice you will see your already damaged healthcare system literally crumble to ruins. You have to realize that whether you like it or not docs are the last line of defense. They are the ones putting in the hours to keep the ship afloat, which is why you have to pay them well. You are right in saying there are dishonest people in medicine, but if you want change then target the industry and their lobbyists. It will be much better for you and everyone else, and will bring some of the changes you seek.

I'm not even arguing a massive conspiracy, to be clear. Not all doctors are Tom Price. I don't know how it works with the ADA, but my guess is the stuff is mainly tradition, and economics informs tradition unconsciously.

And yes the institutions that most want to pay doctors left are totally untrustworthy with that money. So I am not advocating letting them do that.

I guess I'd like:

1. Government health care. Nobody can rationalize the value of their life on their death bed; markets make no sense for health.

2. After that (which fixes the deepest problems), switch to an apprentice style program where everyone starts as a nurse, and then some go back to school to learn more.

The way society valorizes doctors above all (including, implicitly, nurses) (this "last line of defense stuff", etc, etc) strikes me as ungrounded and, frankly, classist or sexist in many instances. There are other well-meaning individuals, and focusing on the individual level, whether patient or care-giver, is not the right approach to systemic problems.

What I meant to say is that in the current structure it's like that and unfortunately very real. It can be changed, but probably at both a high cost and a profound cultural change. Your current social contract as a doc is

1. Do the job that is traditionally yours.

2. Handle all the impromptu alone because no one else will do it.

The second part is the problem, and is largely due to ressource constraints.

What's clear is that the system is already in pretty bad shape, so I'm just saying that the frontline workers are not a suitable target for pressure. BTW your view regarding the nurse to doctor transition would have been ok 50 years ago. Nowadays, nurses are hyperspecialized in their own niches. If you meant to say "you should know how to make a bed before doing heart surgery", I heartily agree that it would do great good to everyone if docs were to experience what life is lower down the care ladder.

Thanks for replying this far after the life of the thread.

I was aware that nurses are far more trained today. But is their training that orthogonal to the doctors? I was thinking doctors starting with nurses in tandem with nurses allowed to operate more machines, do more radiology, etc.

Well, yes you can do that for some theoretical knowledge, but it wouldn't be very practical on the job because indeed, they are not the same jobs at all. The role of nurses is to handle the expected as efficiently as possible. The job of docs is to handle anything unexpected. That is why a wide education is necessary.

You may also be surprised by the fact that specialist nurses are well paid and would often never want to "upgrade" to being a doc, precisely be cause of the additional constraints. Finally, the ego of specialist nurses rivals that of docs, and they are even stronger unionized. I don't think it's really possible to keep the same quality of care for cheaper by changing education because armies of residents and fellows are effectively doing slave labor and you'd have trouble finding cheaper and more efficient than a highly-trained slave. In my opinion, well applied technology is the only long term solution.

>Med school -> Memorization school

At a bad medical school, maybe.

Pretty much anything can be taught as blank facts, versus a method that stimulates critical thinking.

Programming, for instance. ;)

Reply on news.ycombinator.com