Medicine, the Epitome of Tangential Learning

"You only really learn medicine by doing"

As luck would have it I started my career in Emergency, an excellent all-rounded rotation for a beginner. 6 weeks into the job and I finally feel like a doctor; making real decisions and judgment calls that affect real people. I am also at long last starting to be decent at all the minor practical stuff such as cannulations, catheters and suturing.

Medicine has a lot more to do with mid level management than people realize. Patients take time to manage. In a typical 10 hour shift, I have seen between 3 and 10 patients. Often, patients take a lot of time to work up - chasing records and drug charts from their GP, digging a history out of the patient (this can be tricky and patients are often really really terrible at describing their own condition), and documenting everything for medico-legal reasons.

As an Intern (read: apprentice) I am also expected to doublecheck everything with a senior officer before enacting my plans. Judgment calls will be scrutinized, decisions would be double checked. If my plans are inadequate, or I missed out on a key investigation/examination, then I would be informed by a senior. This is all for the safety of the patients and to ensure they receive an appropriate level of care. Knowing what to do (how to manage) to a patient presenting with a condition is tricky, and is the reason why medicine is only really learnt in practice, tangentially. Textbooks are great and all but nobody ever does full systems exams such as those found in Talley & O'connor. The key mental processes that need to be assimilated into your chain of thought when making decisions about patients can only be formed in practice, and this is really what internship is all about.

"Tangential learning is not what you learn by being taught, rather it is what you learn by being exposed to things in a context that you are already engaged in." - James Portnow. 

Say middle-aged Jane Blogs presents with abdominal pain. I've taken bloods and done my bog standard gastroenterology history and examination. Ms Blogs now demands pain relief. What should I give her? Her pain does not warrant strong opiates, so I decide to prescribe some paracetamol/codeine and ketorolac (an NSAID like ibuprofen but a bit stronger). I run past a senior officer and describe her symptoms and my findings from my examination. Blood results are pending. "Can I give her some panadeine forte and ketorolac in the meanwhile?". STOP. The senior advises to withold the ketorolac until I know for sure that she is not pregnant. This is a lady who presented with abdominal pain, but I have not done an O&G history. For all I know she could be having pain related to pregnancy, whereby NSAIDS are contraindicated. If she had been trying to get pregnant for years (and being middle aged it is very difficult to do) and an NSAID triggered a miscarraige, excrement would have hit the proverbial fan. "Just call the lab and request an addon for B-HCG (a pregnancy hormone)" the senior advises. The bloods come back, no she's not pregnant, and pain relief is given as planned.

It's things like this that make internship mandatory in all countries and why it is irresponsible for fresh graduates to be left to make important decisions about patient care. Medicine isnt really learned in medschool, it is learned through the hours spent managing patients. It's not rocket science.

For the first time in years, I actually feel like studying. Now things really make sense and reading the books are a breeze. As a student you tend to read for knowledge alone. Today I read through the lens of a manager, and could far more easily visualize myself in the situations described by the literature. It is so much more real to me.

The most learning occurs when you have a query and subsequently research that query. This is tangential learning in action. Say a person presents with a headache. My knowledge of the subject is superficial at best, so I look up BMJ's Best Practice and UpToDate on how to best manage my patient. I quickly figure out what I have to exclude (eg subarachnoid haemorrhages) and the likely common differentials. Now not random Joe coming into Emergency with a headache will get irradiated (CT Brain). When do you really need to order one? Or when does the kid with the abdo pain need an urgent ultrasound to rule out/in appendicitis? Or in a patient with sudden shortness of breath, is it really a good idea to order a test for a clot in the lung if the chance of a false positive is high? Questions like these pop up all the time, and very often as a junior medical officer I cannot make the judgment call with confidence. That's when the senior staff step in and provide advice and assistance. The stuff that you learn hands on, in the moment, at the scene, is priceless. It is tangential learning at it's finest.

There's a catch. Tangential learning requires interest in the subject to work. I guess that is where some people start to realize maybe medicine is not for them.


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