Each Thursday, the Daily Voice showcases selected Thursday Morning Memos, reflective essays about clinical experiences written by faculty, alumni, residents and students of the Department of Family Medicine & Community Health. Thursday Morning Memos is UMass Medical School’s homegrown version of narrative medicine, in which the authors process their experiences through writing. To learn more, visit:http://www.umassmed.edu/news/articles/2011/personal_stories.aspx
Shay Hershkovitz, SOM ’12, shares with us a reflection about appropriate questioning of knowledge passed along over the years. What a great success: to still be in medical school and to know not to trust what medicine offers up as fact. –Hugh Silk, MD
Learning How to Think for Ourselves
For decades it was believed that lidocaine is crucial in the treatment of arrhythmias that developed after a heart attack. This dogma was propagated from master cardiologist to student in sacred rituals upon stone tablets atop the mountains of academia. To question was to break the covenant. To doubt was blasphemy. That is, until someone sat down to search the literature and discovered our sacred truth was nothing more than folk tale—in fact, lidocaine was doing more harm than good.
This week, I attended my pediatrics rotation evidence-based medicine lecture, ordinarily a testament to the resilience and determination of a medical student’s ability to keep his/her eyes open. Commonly filled with numbers, statistics and calculations, these lectures usually leave me with a headache so fierce they have me running to the closest CT scanner. I knew this lecture would be different when Dr. Scott Wellman introduced himself with ‘raise your hand if you want to be here.’ Even the crickets held their arms down. A fine, knowledgeable, straight-to-the-point, no nonsense kind of physician, he not surprisingly refused repeated pleas to administer (not less bitterly than a Bernstein's acid test) this lecture. On the third plea, he decided that a) They probably were not going to leave him alone, and b) he needed to find a way to make this lecture more palatable if we were going to let him shove acidic knowledge down our throats.
And so he went on to tell us about the day colleges began asking his newly matriculated patients be screened for tuberculosis status via a Mantoux (PPD) test. A benign intradermal injection, let cook for 48-72 hours, and presto, you’re college bound! What could possibly be the harm? While some doctors may have chosen to check their sense of curiosity and patient advocacy at the door, Dr. Wellman opted to clear precious, non-reimbursable hours out of his schedule, and come to his own conclusion. As he discovered, in his low-risk population with no respiratory symptoms, the chance of a positive screen is significantly smaller than a false positive. Many of these false positive will be exposed to radiation of a chest X-ray, and some will endure nine months of antimycobacterial therapy (in which alcohol is contraindicated. Can one conceive a harsher sentence for a college freshman?). The numbers needed to treat were so far outweighed by the numbers needed to harm, that Dr. Wellman came to the conclusion it is simply healthier to refuse screening. “Test not indicated” is all he wrote back. The outcome? Ninety percent of colleges simply checked off the box and never bothered him again. We then went on to learn how to solve such clinical dilemmas by finding reliable information and how to apply it responsibly in the context of patient care.
Medical students spend their four years frantically sipping from the fire hose of knowledge, memorizing endless facts and figures. We seldom stop to realize that the half life of medical knowledge, estimated somewhere around the length of a medical education, means the knowledge we slaved over to acquire and regurgitate, represents, at times, well intentioned lies. Recently, UMass Medical School was ranked eighth in the country in educating primary care physicians. This spectacular figure is far from trivial. Actually, it is the manifestation of professors and clinicians who teach us not only what to do, but also what NOT to do. Most importantly, we’re taught how to think for ourselves, never stop learning, and how to effectively advocate for our patients. I am tremendously proud to be a part of this tradition, and look forward to passing it on as this institution climbs its seven steps up our own, evidence-based mountain.