The Gap Between Seeing & Doing
The problem with the sold medical education mantra of see one, do one, teach one, is that it glosses over the often painful journey between the first and second parts of that phrase. As William Osler, MD, said, “Medicine is not an inheritance.”7
Surgeon and writer Atul Gawande, MD, MPH, put the issue more succinctly: “Like everyone, [physicians] need practice. That’s where you come in.”
He elaborates: “In surgery, as in anything else, skill, judgment and confidence are learned through experience, haltingly and humiliatingly. Like the tennis player, the oboist and the guy who fixes hard drives, we need practice to get good at what we do. There is one difference in medicine, though: We practice on people. … [T]here have now been many studies of elite performers, … and the biggest difference researchers find between them and lesser performers is the deliberate amount of practice they’ve accumulated.”8
Ten thousand hours. The commonly repeated mantra is that it takes 10,000 hours of practice to become an expert at anything.9 The lay public just doesn’t realize that their physician may be providing their care before that landmark has been reached, and to be honest, physicians are often a little squeamish to describe this process of medical education in any detail.
It is quite possible that patients benefit from this process. They benefit from this process indirectly, because if we never trained new physicians, no one would be left to replace those who had retired. They may also benefit from this process directly; plenty of data indicate that patients seen in teaching hospitals have better outcomes.10 Presumably, this is due to the environment of questioning and re-exploration trainees create.
Despite this, opinion is growing that we should make better use of non-patient resources to teach some of the practical parts of becoming a physician.11 Actors (and manikins) posing as patients are already standard; some of you may have first learned how to perform an arthrocentesis on an artificial joint or a cadaver, for example. But wouldn’t it be great if there were better shortcuts between seeing and doing?
The Virtues of the Virtual
The business world has already begun to embrace the potential of virtual reality for the education of their sales force. Walmart, for example, has purchased 17,000 virtual reality headsets so employees can experience, firsthand, the horror that is Walmart on Black Friday. A facilitator guides participants through the simulation, so they can ask questions about what they are experiencing. What they are experiencing is pressure: The simulation is meant to be as realistic as possible, so every sales associate can be optimally prepared for the big day.12
If only medical training were this advanced.
This is not to say that advances have not been made. Virtual reality modules have already been developed to teach empathy. One company has used virtual reality to place the user in the eyes of a terminal patient, breathing his last breath, so care providers can develop a better understanding of the process of dying from the viewpoint of the patient and the patients’ family.13
Clearly, this is only the beginning. The potential of virtual reality to teach trainees about rare diseases makes the mind salivate. The problem in my clinic is I rarely have a patient with a subclavian bruit show up on the same day that a trainee asks me about Takayasu’s arteritis. On other days, I may tell a trainee: you’re lucky you’re here today; this patient has cutaneous polyarteritis nodosa. You’re never going to see something like this again. I’m sure that the same words have passed your lips at some point, as well. If you think about it, however, there is a certain tyranny that ties medical education to this sort of happenstance.
Now, picture a scenario in which a trainee could don a pair of goggles and see the discordant eye movements associated with an orbital pseudotumor or hear the prolonged wheeze of subglottic stenosis. It may not be as good as having an actual patient at the end of the stethoscope, but it would be a good deal closer to that experience than the descriptive passage that appears in UpToDate.
To my mind, this does not seem all that farfetched. Technology has already been used to convince 200 million players they are parachuting onto an island infiltrated by enemies; the same technology convinces 200 million players to go through this same scenario, again and again, without tiring of it. It seems like not much of a stretch to think the same technology could be used to enhance the game-like aspects of learning and use our inherent need to play as a tool to promote learning and knowledge retention.
They say you can’t teach an old dog new tricks. Then again, they’ve never tried to introduce that dog to Fortnite.
