Ramblings on healthcare, medical education, and life with a spinal cord injury
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Is Medical Education Too Black and White?

Studying medicine while also living with a chronic medical condition provides somewhat of a unique perspective on how disease and various conditions are presented. And recent material we’ve covered has given me pause to consider how things are taught.

The curriculum at Case Med is based heavily on the concept of problem-based learning (PBL). Which means we do a lot of work in small groups (roughly eight students per group, with one faculty facilitator). On Monday morning, we receive two cases. Each provides a narrative describing a particular fictional patient, their signs and symptoms, some imaging and potentially a diagnosis. We spend about an hour per case in our small groups working through the details, discussing elements we need to learn more about and how we will focus our individual research about the cases in question. On Wednesday, we reconvene and discuss the first case, Friday the second case. Small group is augmented by lectures that serve to provide some formal guidance as to the physiology and pathology with which we are presented, a sort of springboard for our small group research.

I think this is an incredible way to study medicine, as it forces us to learn how to learn, which will be infinitely more essential in our future careers as physicians than having memorized the entire list of signs of interstitial lung disease. To be sure, the ability to recognize common conditions and their presentation will be necessary to do our jobs. However with collective medical knowledge expanding at a phenomenal pace, even more important is the ability to quickly and thoroughly assimilate details about something with which we are unfamiliar. But I digress.

Recently, we had a case that was intended to guide our learning of the diaphragm and the accessory muscles of breathing, as well as the various phases and intricacies of the process. Because the diaphragm is innervated by spinal nerves C3-C5 via the phrenic nerve, but the accessory muscles are variously innervated by nerves at the thoracic and lumbar levels, the case we were presented with involved a patient with a spinal cord injury around the level of C4-C5. The idea behind this being that the patient would have at least moderate function of the diaphragm, but no use at all of the accessory muscles. Being able to discuss the topic in depth requires an understanding of all of the various muscles, what they each contribute to the process of respiration, and how they are impacted by a neural deficit.

However, during the course of the case, no mention was made of the classification of the patient’s SCI: complete or incomplete, or what the ASIA level was. Unfortunately, without this information, it becomes a lot more difficult to fully ascertain how the patient would fully be affected. As the case was not intended to be a neuro case, going into great detail on the ASIA scale or all of the other items impacted would be inappropriate. But without understanding at least that there can be tremendous variance in how patients are impacted by spinal cord injuries, it becomes impossible to really know this patient’s situation.

Of course, I’m in a unique position and am acutely aware of these differences. I’ve had to learn it as I’ve lived it, and as someone living with an incomplete SCI, I’ve learned just how bafflingly variant such an injury can be. Some muscles may function perfectly fine, while others that are controlled by nerves higher up the spine are more poorly innervated than those further down. It’s impossible to predict the items that will be affected in an incomplete SCI, which is why patients comparing functionality between ourselves can be nigh on useless.

During the course of discussing this case, I tried to mention a few times the concept of complete versus incomplete, and reinforce the idea that incomplete can be a vastly inconsistent diagnosis. And people in my group seemed to either already be aware, or they came across it in their research for this case. But in talking to friends, it was clear that other groups didn’t seem to be aware of the concept and some students were under the impression that such an injury is simply binary: all or nothing. You’ve either got full functionality, or none.

Nothing could be further from the truth.

Which got me thinking. If the extreme variability that is central to even scratching the surface of an SCI wasn’t covered, what about other conditions? And as I began to focus more on how other conditions are presented to us, I started to realize that many cases are presented as “here is syndrome X, and here are the associated symptoms.” No mention is made of how variable something may be, or the depth of different manifestations.

I discussed these thoughts with some classmates, and many of them shared the feeling that it seems medical education may be a bit lacking in regard to the spectrum with which various ailments appear. Perhaps this is considered an implied undertone to everything we learn. Perhaps it’s something we’re assumed to pick up in third and fourth year, when we’re immersed in the clinical aspect of medicine every day. Perhaps it’s something we’re assumed to learn at some other point in time.

Whatever the case, my own experiences have made me more acutely aware of such variance than I otherwise would have been when considering anything that we study, as have those experiences done for several classmates of mine. Which in the end, I think, makes us all more versatile and adaptable as a result.

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