Medical Student Tirade #1

Perhaps it is me becoming more demanding, but as the years have gone by, I have noticed that the general standard of medical student knowledge has been falling. At the risk of sounding like Grandpa Simpson ("Back in my day...") when I was a medical student I was so freaked out at everything that I was expected to learn and know that I'd constantly be looking things up (and forgetting them), and would always carry my trusty little Oxford Handbook of Clinical Medicine (or Surgery). Anything my registrar or consultant told me was gold, and I'd write it down. The more I listened to what they talked about the more I learned. This was particularly important given that I'm pretty bad with learning off the printed page. Anything I got asked that I didn't know the answer to was either an exercise in first principles (which have served me well) or a trip to the library.

Unfortunately, I have increasingly found that medical students (especially those doing PBL-type courses) have become less knowledgable, but more worryingly, less concerned about their lack of knowledge.

It is not uncommon that my students do not know how to test properly for visual acuity. They don't know what the normal intravascular volume of an average 60kg man is. They don't know what the inguinal ligament is, or what is at the mid-inguinal point. They don't know the difference between dysphasia and aphasia. They think that bunions and gouty tophi are the same thing as hallux valgus. Worst of all, they don't really seem to care.

I often walk into tutorials, planning on teaching a session on joint examination, or abdominal examination, CNS examination, or fluid-balance management, and end up getting no farther than explaining the difference between anterior / posterior, dorsal / ventral, superior / inferior, proximal / distal, or discussing the organs within the abdominal cavity, listing the cranial nerves and their functions, or discussing the waves of the JVP. This is basic knowledge missing from medical education today. There is so much focus on "validated educational processes", "problem based learning", "modular assessment and feedback" that it is making medical teaching inefficient. Students do not have enough application, time or ability to learn a large amount of knowledge in a few precious years. Instead, they learn a small amount of selected knowledge in an "educationally validated, continuously assessed" manner. We have forgotten that doctors (especially "junior" doctors) have always been relied upon to have a strong grasp of all aspects of medicine, and have all been seduced by the theoretical attractiveness of the PBL system.

These students can carry out the "moves" of a clinical examination. They ask the "right questions" on history taking. They have no concept, however, of why they are doing these things, or what the answers mean. The PBL course is supposed to encourage lateral thinking at the cost of basic sciences knowledge. I believe that it has failed in both regards when a final year medical student cannot tell that a patient has a false eye, or situs inversus, or is clinically dehydrated despite demonstrating numerous clinical sign that that is the case. When a patient with a weak, cool, numb leg automatically has "acute PVD" but a stroke is not a differential diagnosis. It is a disgrace when a final year medical student thinks that 20 seconds of scrubbing without removing their watch is acceptable before a surgical procedure. Even worse, they time their 20 seconds by singing 'Happy Birthday' in their heads. What is the world coming to?

I fear for our health system in the coming years. I fear even more, when I hear that postgraduate training will be shortened, rather than lengthened to compensate for these problems. We had better lower our expectations, because standards sure as hell will not be going up.