Ruth Armstrong: Medical thinking

I AM a product of problem-based learning. At the age of 18, with vague misgivings that I was part of an educational experiment, I sat in a tutorial room at the University of Newcastle with seven similarly apprehensive colleagues, ready to “problem solve” our first case.

Over the years, I’ve been asked if the Newcastle approach was better than the other medical courses available at the time but, of course, I don’t know. Thankfully, I only had to do one of them!

This week in MJA InSight, one of our news stories looks at whether problem-based learning (PBL) deserves its place as the main teaching vehicle in many Australian medical schools. We asked medical educators to respond to an MJA “Perspectives” article about the lack of evidence underpinning PBL’s ascendancy, and the need for medical schools to expand their repertoire of learning paradigms and teaching methods.

John Hamilton, a veteran medical educator and ex-Newcastle dean, directed us to a paper he published in the BMJ in 1976, critiquing the (then new) technique. The critique included a quote from John Dewey, a 20th century philosopher and educational reformer, which caught my eye:

“… science has been taught too much as an accumulation of ready made material with which students are to be made familiar, not enough as a method of thinking, an attitude of mind, after the pattern of which mental habits are to be transformed”

This holds true for medical training no matter what methods are used.

The idea that a well trained doctor is one who has learned a “method of thinking” is reflected in our lead news story, about the use of high-sensitivity troponin assays in patients with suspected acute coronary syndromes. The authors of an MJA editorial affirm the potential of these assays to improve patient outcomes by picking up more cases of myocardial infarction. However, they caution that advances in diagnostic technology needed to be accompanied by “more effective clinical practice” — including an understanding of who should have the test, what the results mean and how to use them to improve management.

In our other news story, an expert calls on health professionals to have a more structured and deliberate method of thinking to determine if children presenting to hospital have been victims of abuse or neglect.

Commenting on an MJA editorial about the difficulty of obtaining accurate data about child maltreatment, Emeritus Professor Kim Oates said that when hospitals have clear protocols for identification of child abuse more cases are identified, and that doctors needed help to ask “the difficult but important questions”. Such a protocol has been used for some time in Queensland, and has recently been introduced in NSW.

Back in June our regular blogger Jane McCredie wrote about the ethics of administering anaesthetic agents with the intention of altering memory, sparking reader debate about the extent to which this is possible. This week Simon Hendel provides an anaesthetist’s perspective on anaesthesia and memory, as well as some advice to be mindful of patients’ reduced capacity to retain memories of events immediately after surgical procedures.

Jane’s column this week, looking at how evidence-based medicine (EBM) is just catching up with a common problem, reminds us that while EBM serves medicine very well, there are still gaps in the evidence that require rethinking, support and funding.

I’m not the only one living in the past this week. The ever-nostalgic Aniello Iannuzzi tells us in his comment that “Once upon a time, choosing a university course in health meant a secure and rewarding career” but that the whims of successive governments have dictated that this is no longer so.

He may be right but I am optimistic. If these young graduates have been equipped with “a method of thinking” to undertake lifelong learning and mindful practice, the future looks exciting for them and for medicine.

Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight