Slowing Down the Med Ed Express

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By: John Henning Schumann, MD, interim president, University of Oklahoma – Tulsa

In their perspective “Slow Medical Education,” Wear and colleagues deliver an earnest argument for planting reflective practices into the continuum of medical education. It’s hard to find fault with such high-minded advocacy, but as a former internal medicine residency program director, I wanted more—for example, concrete suggestions about where in the curriculum such activities could take place. Living in the era of severe work compression, conceiving of a spot for periodic reflective activities has an aura of adding one more check box to an already overcrowded list.

To over-generalize, there are two kinds of residents: one group that during training is able to balance themselves and periodically engage in reflective activity to put medicine in the context of their lives. The other group experiences residency as a hurdle to overcome, a prescribed period of experiential learning to get through. And oh! — let those “touchy-feely” topics be damned.

Naturally, this oversimplification discounts the fact that all learners are on a continuum. When I was a resident, I strongly felt the need to learn what my seniors and attendings offered me, keeping an anxious eye on the far away mountain of the ABIM certifying exam. Yet there were many traumatic moments—deaths, codes, crises, uncertainties, ethical dilemmas, etc., that yanked me off the express train that is residency at least for a station or two to reflect on what was happening to me.

Daniel Kahneman’s Thinking, Fast and Slow provides a useful framework for trainees’ progression through graduate medical education. So-called System 2 (slow) thinking, the type that is “effortful, logical, calculating, and conscious” is how we start out as doctors. We have to think through what we do, learn by example, plan our steps, and repeat and rehearse them again and again. We see constant variation in presentation, but our brains are able to recognize patterns as we hone our ability to shoehorn the external into our medical thinking framework. Our goal, in some respects, is to become practiced enough so that as doctors we use System 1 (fast) thinking, the type that is “automatic, frequent, stereotypic, and subconscious.”

The organizers of graduate medical education in the U.S. might include progression from System 2 to System 1 thinking as an aspiration in concert with the new milestones we use to evaluate learners under the ACGME’s Next Accreditation System. While I’ve found milestones useful in more clearly articulating what it is we want from our fledgling physicians, I continue to believe that graduate medical education inadequately imparts adult learning context to our learners. An important caveat of experiential adult education is striving to understand our context—reflecting not only on the skills and knowledge we acquire but also on what happens to us emotionally as we progress. Most graduate medical education programs are unable to place residency education in its appropriate economic, social, and political contexts, instead placing nearly all emphasis on the process itself. Such disconnectedness creates a fundamental barrier to true reflective practice, and I fear causes doctors to be less resilient when they leave residency training.

Slow Medicine, then, is a natural reaction to a leviathan system of education and practice that has become increasingly sclerotic as the world practically somersaults around it. I find the grassroots feeling of Updates in Slow Medicine (that I reported about elsewhere) equal parts refreshing and slightly subversive. There are myriad other examples of slow movements in medicine, both from inside and outside the medical establishment. From inside, we need look no further that the ABIM’s Choosing Wisely campaign or the ACP’s High Value Care curriculum. From outside the establishment, it’s estimated that we collectively spend in the neighborhood of $40 billion per year out-of-pocket for complementary and alternative medical practices. That’s a critical signal to us to desist from business as usual and re-think our health education and delivery frameworks.

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