In 1950, doctors in practice could expect the total amount of medical knowledge to double every 50 years. By 2020, it will take just 73 days. How’s a young doctor supposed to keep up while managing the hectic pace of practice?
In residency, I was surrounded by educational opportunities. With lectures, grand rounds, and most importantly, a deeply skeptical cohort of residents who questioned anything and everything they were told to do, it was hard to not stay up to date. Now, as I start my practice in primary care, I find myself unsure how to best tackle the ever-growing field of medical knowledge. I decided to phone a friend for advice.
Dr. Rachel Stark is the associate director of the internal medicine residency program at Cambridge Health Alliance, and has been in practice for twelve years. Between her roles as an administrator, educator, and physician, she manages to engage with the ever-changing state of medical knowledge. We sat down in her office to discuss how she keeps up.
Ask the Right Questions
The first step to remaining current, Dr. Stark said, is to retain a sense of curiosity about even the “mundane, everyday work” that internists do. Without that sense of curiosity, we stick with diagnostic and treatment algorithms that are flawed or out of date.
“Part of the process of being an internist is being able to identify and articulate a well-reasoned clinical question,” she explained. “Once you do that, you’ll have a much better ability to find an answer.”
For instance, in diagnosing the flu, we often rely on flu swabs. But I noticed a discrepancy between my clinical diagnosis of flu and the swab, which was often negative. With this as a spur, I found that rapid diagnostic tests have a specificity of 90%, sensitivity as low as 42% in clinical practice. Therefore, these tests can be used to rule out, but not rule in, the diagnosis of influenza. I am now much more likely to diagnose flu and to use swabs mostly when I am concerned about institutional outbreaks.
Choose an Environment that Challenges You
In How Doctors Think, Dr. Jerome Groopman dissects the most common cognitive errors in medicine, from diagnostic “anchoring” to “confirmation bias.” With intense time pressures and demands from patients for definitive answers, once we are out of the intense environment of residency we can be tempted to stick with diagnoses and treatments that we are familiar with, and to ignore research that conflicts with what we already know.
As an antidote to this, Dr. Stark’s advice for new doctors is to work in an environment that is “always challenging.” For her, the challenge primarily happens through her role as an educator. “When you’re responsible for your patients but you’re also responsible for a generation of physicians behind you,” you are pushed to practice the best available medicine, she says. For those of us not involved in day-to-day education, we are still working in teams with colleagues who will have different practices that should inspire us to examine our own assumptions. We can also be better team leaders and physicians by encouraging everyone working with us to bring up questions in a non-threatening environment.
Facebook Is a Fun Place to Argue About Science, Too
Social media is not for everyone, and Dr. Stark is not into it “at all.”
Personally, I like Facebook and Twitter for knowing what experts and non-experts are talking about, especially because a link to a research paper is usually included in well-written articles. If I think something is incorrect or misrepresented, I often respond, which starts a conversation with my friends in health care, who may have a different take, and friends outside of health care who have interesting and practical questions. In answering them or sharing information, I practice what I consider to be one of our hardest and most important skills: explaining uncertainty to patients.
Let Others Curate Resources for You
Dr. Stark subscribes to a number of resources that narrow down the vast number of articles published every day to a dozen or so that may be relevant. She pointed to NEJM Journal Watch, and the American College of Physicians’ Journal Club, which she said breaks down “the study design, the number need to treat, the number need to harm,” its quality, and the context of what came before. She also scans the table of contents of The New England Journal of Medicine and the Journal of the American Medical Association and reads articles that are relevant to her practice.
Staying Current Is Our Commitment to Our Patients
Given that medical knowledge is doubling more than once a year, I asked Dr. Stark if it is even possible to stay up to date. She responded that the constant change in medicine is one of the things that makes being a doctor a great privilege. “It can seem daunting,” she said. But we have to make curiosity “the foundation of our care of patients.” This, she concluded, is “our commitment to our patients.”
Elisabeth Poorman is a primary care doctor at Cambridge Health Alliance-Everett and a recent graduate of Cambridge Health Alliance’s Internal Medicine program. She tweets at @DrPoorman.
This post is part of the “Lifelong Learning” series. Posts on this topic include:
A Mid-Career Perspective on Lifelong Learning in Medicine, by John Mandrola, MD
Keeping Up with Core Medical Knowledge, by Natalie Levy, MD
Keep Learning Even When You’re Not Studying for the Boards, by Sara Cohen, MD
I Studied for the Internal Medicine Boards on the StairMaster, by Monique Tello, MD
Getting It Done: Four Tips for Learning Efficiently, by Jalan Burton, MD
Why Is It So Hard to Ask for Advice? by Sara Cohen, MD
More advice for new doctors:
NEJM Resident 360
Helping Struggling Learners Succeed Through Resident Coaching, a Q&A with Roy Phitayakorn, MD
What to Do When You’re New: Tips for Physicians from Author Keith Rollag
Being agree with Dr Elizabeth Poorman that the Medical Knowledge can be doubled in 75 days, the fact is that the very important and evidence based knowledge, is not increasing in that way.The problem that we are facing(between many others) it is how we can find the Knowledge that really has been produced through a very good and Random Research, carried by outstanding researcher (or a very well and intelligent team) in a well designed trial.
We know now, that 50% of all Psychological Trials can not be reproduced and the 25% of all Medical Trials, has the same problem.(remember the danger produced by an false medical investigation, where the author, in Lancet,concluded that Timerosal used in many vaccines, was related to Autism.The name of that *DR* was Andrew Wakefield)
I think, that now, there are a lot of Journals , where many Researchers, sent their papers, with irrelevants articles, .This is produced because for many reasons(bad stimulus), Drs has the obligation to publish.
She say the thruth=there are serious Journals like=NEJM-ANNALS-LANCET-NDT(European Union),,COCHRANE where we can to look for well done reviews-guidelines-reasearch, .
Another timely publication is Prescribers Letter — a quick and interesting read. (Disclosure: I have no financial conflict of interest.)
High specificity tests rule in a diagnosis, low sensitivity tests cannot rule out a diagnosis. You can confirm a diagnosis of flu with the rapid diagnostic test, but you cannot determine that a patient presenting with flu symptoms does not have the flu. I think you may have it backwards. (Paragraph 6)
You are correct! I switched them in my explanation. Thank you for catching.
Dr Stark has elucidated a great conundrum in contemporary clinical care.
As a long-time primary care clinician and, now, fortunate enough to be involved in the teaching of new clinicians, I have always found the axiom that “the good clinician knows what she/he does not know” is a great spur to enhance and expand one’s knowledge.
If you question yourself, you will want to look for the answers.
That is true even if the answer is different now from what it was when you last asked the question.
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I get severe hot flashes and have noticed that they come on very frequently when the air conditioner or heater comes on in the house, could it be that these appliances are emitting certain chemicals in the air and which ones are they? spoke to another person who also admitting getting hot flashes from her air conditioner, this topic needs extreme research because scientist may be able to come up with a solution for this when they test certain chemicals causing this???