Creatures of Habit: Can a Doctor Ever Unlearn?
By Andrew J. Jones, MD, Medical Writer
Despite the inability of most Americans to see eye-to-eye these days, no one can deny one simple fact: doctors attend a lot of school. And rightly so! One must learn an outrageous amount of information in order to be trusted with life and death decisions. You may have heard the tired analogy that medical school is “like drinking from a firehose.” While I detest this comparison for its overuse, I likewise think that it doesn’t fully approximate the experience. Consider this instead: medical school is like condensing your entire four years of college into one year. Rinse and repeat. Follow that with a three- to seven-year residency and then maybe a one- to three-year fellowship. After high school, you’re in for a minimum of 11 years to ultimately get board certified.
It would be impossible to practice medicine in today’s world without picking up a medical journal or participating in continuing medical education courses. But what do we know about unlearning?
Obviously, a premium is placed on learning. One must learn all the bones, all the cells, all the biochemical processes that make Homo sapiens a viable organism. Medical schools have increasingly placed an emphasis on the “lifelong learning” model due to the sheer volume of new data that are shoveled out on a daily basis. It would be impossible to practice medicine in today’s world without picking up a medical journal or participating in continuing medical education courses. But what do we know about unlearning? In pedagogy (the study of learning), unlearning refers to the process of intentionally ignoring information that was previously retained. A 2017 study by Gupta et al addressed this topic and examined how the physician unlearns. Naturally, some interesting trends emerged.
The investigators interviewed 15 physicians who were mostly classified as “primary care” and who had a substantial portion of their practice centered on direct patient care. The interviews were conducted face-to-face and consisted of open-ended questions that encouraged the sharing of personal experiences. After some complex coding and data analysis, the investigators proposed the following conclusions:
- Practice change disturbs the status quo equilibrium—establishing a new equilibrium that incorporates the change may be a struggle.
- Part of the struggle to establish a new equilibrium incorporating a practice change involves both the evidence itself and tensions between evidence and context.
Most professions are reluctant to accept tectonic changes without significant experience in the new model. Medicine is no different.
Most professions are reluctant to accept tectonic changes without significant experience in the new model. Medicine is no different. In my experience, there are a handful of older doctors who are set in their ways and who have years of anecdotal experience to back up their practices; however, I believe that practice setting may affect this phenomenon more than age. A doctor practicing in a rural primary care practice will definitely have different methods of learning and unlearning than a neurosurgeon in an academic hospital. While keeping up with the literature is important for best practices, empirical knowledge is also invaluable for learning medicine.
One of my favorite surgical attendings was a 73-year-old doctor who had been a surgeon for over 50 years. He was incredible at forecasting what would happen to a patient in the coming hours, days, or weeks even at times that made no scientific or medical sense. He truly had seen it all, but he was also acutely aware that he could not keep up with the hourly deluge of new data. So he relied on us youngsters to read and study while he doled out the wisdom that can only be gained through blood, sweat, and tears. It was a great system that allowed us all to work together for the greater good.
It is equally important to be introspective when unlearning. Because the nature of science is to question, I agree that evidence-based medicine should be challenged.
It is equally important to be introspective when unlearning. Because the nature of science is to question, I agree that evidence-based medicine should be challenged. We as scientists should always be asking questions, and new data should be carefully scrutinized with a focus on study design and the numbers themselves. One should draw their own conclusions before reading those of the authors. But introspection can only go so far, and it’s inherently dangerous to rely on one’s own experiences over a more formal scientific process.
For example, I have worked with many physicians who went through a singular experience with a patient that was so personally traumatizing that it changed the way they practice medicine. While this is to be expected, it should be approached with caution. In fact, Gupta et al describe such an anecdote. One respondent described a “lovely patient” whom they felt died a premature death from prostate cancer because the respondent failed to order a prostate specific antigen, or PSA, in the patient’s bloodwork.
“I kept thinking if I had done the PSA maybe I could’ve saved him. So after that, evidence-based medicine was out the window and I’ll sneak in PSA into people’s blood work and not even tell them. I’m exaggerating a little but I’d say let’s get a prostate test today, so they’d say yes so I’d throw it in there. I would rather live with causing biopsy problems or a surgical complication than to have someone die because I didn’t check.”
While I appreciate the impact of such an experience, I believe that throwing evidence-based medicine “out the window” is the wrong practice to unlearn. This emotional response could lead to worse outcomes for future patients. After all, the reason for changing the guidelines stems from the observation that many men have prostate cancer on autopsy that was clinically irrelevant in their lives. In other words, they died from something else and were blissfully unaware that they had cancer. By contrast, what if this patient had gone down the road of cancer work-up? What if they had died on the operating table from an unnecessary prostatectomy? What if they did have a “biopsy problem”?
Overall, I believe the answer to these questions lie in the study’s second conclusion. A clinician needs context in order to make the best decision. Every patient is different in virtually every way. Two patients with heart failure may share no other characteristics in common, and even their shared disease could behave very differently. This is why the scientific community must attempt to identify patterns and draw conclusions based on population medicine that may or may not apply to every single patient. Herein lies the science and the art of medicine. This is why physicians must listen to their patients. This is also why being a doctor is so hard, and why unlearning may be just as important as learning.
Open Access Citation:
Gupta, D.M., Boland, R.J. & Aron, D.C. The physician’s experience of changing clinical practice: a struggle to unlearn. Implementation Sci 12, 28 (2017). https://doi.org/10.1186/s13012-017-0555-2
Published by BMC, Part of Springer Nature