They say to become truly educated is to begin to realize how little you really know. I used to not understand this — it seemed the more I learned, the more I knew. How could it be different? This changed in medical school. It was only then that I began to feel more and more ignorant with each passing day of my education.
Each day in medical school, a gigantic bounty of knowledge rains down from the heavens. Learning at the pace demanded of us is likened by many to trying to drink from a fire hose — a comparison I thought was silly before I realized it was accurate. The curriculum of medical school is roughly what one might expect — most of our time is spent learning about the human body in health and, more predominantly, in sickness. Our curriculum overflows with sessions on how to recognize, diagnose and manage disease. But our discussions of these maladies are, almost always, limited to only what is clinically relevant. Which is to say, much, much more could be taught to us about these diseases than what actually is.
Every now and then I steal a glimpse of what lies beyond clinical relevance. Due to either a special interest or, more often, a profound confusion, I venture beyond the lecture material and open a textbook or look up a scientific paper. The land beyond clinical relevance is terrifying for its immensity and overwhelming complexity. Each disease is its own world; the clinical exhibitions are like the shadows these vast and complex worlds cast onto a wall. Each day in the classroom projects the images of ten, twenty or, even, on a busy day, thirty new worlds. And there are enough human diseases to suggest that this pace could continue for the rest of your natural-born life.
Our time in the lecture theatre is punctuated by clinical encounters with real patients usually once or twice per week; these occasions reveal entirely new forms of ignorance. For one, these episodes expose an endless parade of patients I don’t know how to treat. What’s more, additional dimensions of disease make themselves known. Rigorous scientific, conceptual understandings of diseases as entities in their own right are nudged aside by human, narrative impressions of disease. Of course, one can’t just forget about all the science, but one has to consider the science along with all these other dimensions. Diseases aren’t objects; their sole realm of existence is in the lives of people. It is hugely important that a doctor learn to interact with all the humanistic aspects that a patient brings to bear, and, since each patient is a different human, each patient encounter is potentially educational. Even if you succeed in learning and understanding all the scientific aspects of disease — the signs and symptoms, the pathophysiology and the genes involved — there is still more to know.
A bit of cognitive dissonance arises from the fact that, although our education is not designed to have us know everything, we are in another very real way expected to know everything. The expectation is present in society at large — don’t you want your doctor to know everything? — as well as in most medical schools. I recall a pre-exam review session in one of the first courses, Blood & Immunology, of the first year in which a classmate asked the professor what were the most important points from one of the assigned readings. There were many assigned readings in this course; my friend was asking about one in particular that had been prepared as a word document by the professor and contained everything we could ever hope to know about neutrophils (one of the bacteria-killing cells of the immune system). This document was, as you may imagine, a bit on the hefty side, and my classmate was curious as to which main points of emphasis we should observe.
A wave of confusion swept across the professor’s face. His colon tensed and his spine stiffened with indignation. The notion that any portion of his beloved assigned reading might be unworthy of our deepest consideration or command something less than our full attention was, to him, unfathomable. Our laziness baffled him. “This is medicine!” he exclaimed. “You have to know it all!”
In a very real way, this is what one signs up for when one accepts an offer of admission to medical school. On the very first day of orientation, the Associate Dean of Medicine said to us, “From this day forward, your education is no longer for yourself. It is for your patients.” There may be some irony in attending a lecture on the topic of sleep while you yourself are months behind on your sleep, or in hearing your dietetics professor recommend no more than 400 mg caffeine daily when you are pretty sure no one has ever made it through medical school on that paltry amount (sincere congratulations to anyone who has). But to indulge too deeply in this irony is to miss the point of the whole endeavor.
The struggle is not in vain. The workload that at times seems crushing is necessary to develop the skills and knowledge needed to enable the project of medical practice. There are tantalizing glimpses of competency along the way that foreshadow a future of, hopefully, expertise. A few weeks ago I correctly made a diagnosis of adhesive capsulitis, a rare cause of shoulder pain. That same week I glanced at a patient’s chart and knew from their list of current medications — furosemide, digoxin, and metoprolol — that they were suffering from congestive heart failure. Baby steps, but steps nonetheless. Of course, I will never know it all; neither will any other doctor, and, of course, neither will any medical student! But, as always, the safest bet seems to be to aim high, fall short now and then when it’s unavoidable, and then continue to aim high.