Transcription
I think that med school is harder for your generation than it was for mine, but not for the reason that you think. You think it's because you've got a lot more to learn and all of the molecular. Well, that's not right, because what you've got to understand is, with all that molecular comes greater understanding, so that you can actually tell a more complete story than we did. So while there's more to learn, it's a better story and easier to remember. So the reason it's harder is not that. In my opinion, it's harder because you guys are learning from the desk and not from patients and autopsy rooms.
So let's talk about what that means. If we go way back to the beginning of modern medicine, so we're talking William Osler. He said this shocking idea, and it makes you laugh to hear it. He said that the reason your patient has the symptoms and the signs that you find is because it correlates with abnormalities in their bodies. And that is a whole multiple generations of ideas called clinical pathological correlation. I mean, it seems laughable now, doesn't it? But it's actually a profound idea.
I'm Doctor Philip Tisdale. I practice medicine for over four decades. I've been teaching for over 10 years. Every system in my book starts with the chapter labeled Clinical Pathological Correlation. You're gonna want that book to be able to follow along, so click the link in the description. One of the benefits of my extreme old age is that I go way back into parts of history that really just aren't talked about anymore. And it's hard to believe that medicine is so much better now. Doesn't mean that today's doctors are better doctors. It means that they have better tools.
But if you go back to my day, I started before there was widespread CT scanning and MRI. Physicians simply had to be better at physical exam. The challenge that they faced was they had these very insensitive and non-specific tools like the stethoscope and palpation. And so lots of times they literally didn't know what was going on. And because of that, quality in medicine was based on autopsy findings. When I first came out in practice in the early 1980s, over 50% of hospital deaths would have an autopsy. So my life as a young practicing pathologist was to come in each day and see who had died and then call medicine and surgery teams and say to them, "When did you want to do the autopsy?" Can you imagine that experience? This was a patient you might have cared for for years, and now despite all of your best attempts, they had died. I mean, it's clearly failure, and it was obviously very upsetting because now you're coming down to the corpse of someone you might have known for decades, and you had to understand, was there anything we could have done better?
And so I would be there with their patient, and they, I would say, "Did you have any questions?" And you know, someone would say, "You know, I never knew what that lump was in the right lower quadrant." We had no imaging. And so we would open the abdomen, and I would go in, and I'd say, "Well, it's a 3-centimeter abscess." And everyone would go, "Well, that explains it. And I wish I'd known, because then we could have drained it." It was such a profound idea, and our tools were so limited back in my early practice days that somewhere between a third and a half of all autopsies would find significant enough abnormalities that were missed that it would have altered patient outcomes. And so everyone in my generation has this very deep relationship with this idea that your patient has underlying pathology that you personally have to discover.
And the way we would communicate that was what we would call morbidity and mortality rounds. And of course, quickly it became slang to death rounds. But this was the most important intellectual event in our hospital. The doors were locked, no one was allowed in but the doctors, and the pathologist would discover what he found, and the attending physicians would criticize each other for, should they have found it? Was it knowable? Would it have changed things? These were deep, very personal events, and we were all very close because we trusted each other with this idea of clinical correlated to pathology.
The other thing that it did was it developed this idea that you started with a patient who had a disease time frame, and there was a really deep idea that was called natural history. And it meant, what happens if we did nothing? And all of us would know this because, by large, we didn't have a lot of tools. I mean, we had some antibiotics, a few handful of cardiac drugs, but really, most of what we saw was natural history. Absolutely true in cancer. And so because we had so few treatments and they were so toxic, everyone would understand if you didn't know natural history, what happens if we do nothing, you wouldn't know whether it was worthwhile doing your treatment or not. Every treatment has side effects, so every treatment is a risk-benefit calculus. Now we have such marvelous treatments, you don't intuitively think of it. Trust me, 50 years ago, we all thought of it.
And so you can see, as I came to teach and everything was broken into these small little domains of small subject-based experts, I grew increasingly frustrated that students were lacking this totality. They were lacking two fundamental ideas that all of us knew from experience. The first was, all of your patient complaints correlated to something underlying in pathology. The tool you used to discover it was really a trade-off of sensitivity and specificity, but not the idea. It's not a magic wand where a report comes out of imaging and gives you the answer. It seems like magic, but for those of us of our generation, it's merely a better tool.
And the second idea is natural history. I had to actually write a whole chapter on chronic progressive disease, Chapter 3, because it's not intuitive to your generation that you start with a well person and they go through this disease progression of homeostasis, adaptation, then intermittent failure, and then permanent failure. I actually wrote a whole chapter on it because it's not intuitive if everyone's parceled into their specialty domain and only answers a specific problem in the patient.
So the more I taught, the more I realized the problem that we had with two things. First of all, the first two years were taught by PhDs. It's not that there's anything wrong with a PhD, but they are, by definition, subject-based experts. They can't tell you why you're learning that. My generation, they were useful, but we were overall taught by practicing MDs. So when we were taught their physiology, it was the physiology they used in patient care. And then the second was, there wasn't this deep understanding of clinical pathological correlation and the natural history of disease. And so as I used all the resources, I just became increasingly frustrated. And it's obviously frustrating with the teaching system. All of you know that, right?
I come into a group to teach a course, and I always start with, "Heart, who doesn't love a panda?" And I always start with this: A patient walks in the door, and they have shortness of breath. Go. And it's a uniform response from our medical students. They give me this look that says, "You mean I've been studying my guts out for two years, you've asked a perfectly fair question, and I have no idea how to answer it?" And I go, "That's right, because it's clinical pathological correlation. The patient has shortness of breath. Why don't you walk me through the organs and the diseases and the sub-diseases all the way to a specific diagnosis? And once you've done that, why don't you tell me where in the patient's natural history are we?"
As I'm now coming out on social media, I have to sort of conform to the needs and wants of social media, and one of them is, you have to capture an idea so that you don't have to keep explaining it. And so you can imagine over the past 10 years, the frustration I've had trying to explain this idea of clinical pathological correlation to today's doctors who have never seen an autopsy. By the way, our autopsies, we did them in little hospitals, half of all hospital deaths when I came out. But over my career, so I start like 1980-two-ish, by 1996, we closed our morgues. The widespread CT scanning, MRI, universal fantastic chemistry, wonderful microbiology, the autopsy really wasn't revealing surprises anymore. You know, you'll hear conventional old-time pathologists say, "Oh yeah, yeah, we need autopsies, they're great." Truth is, they're really not like back in my day. They, those were revelatory.
And so with the advent of AIDS and the need to have sort of Level 4 virus prevention systems, it all went away. Not the need for this idea of clinical pathological correlation, not this idea of natural history of disease, but the way we did it. And so the problem we have now is there are no autopsies. Most of you have never even seen one. We don't all get together by our patients and say, "What did you think was happening?" and then go look. So this really cohesive culture practicing physicians had that always came back to morbidity and mortality rounds, that's all gone. Most modern-day doctors don't practice in the hospital. And so with that, we've lost it in our teaching. The idea hasn't gone, has it?
And so you can see, I'm the lonely voice in the wilderness, looking, wandering around, trying to explain, "You've got to think and teach disease as clinical pathological correlation across a time frame called natural history." I have to explain it, and no one understands it because they've never experienced it. So here we are. I'm staking my ground, and I'm calling this way of learning the right way to learn medicine. You start with a patient, and you have to know where in their disease path they are, and know that their symptoms and your signs relate to the underlying pathology. And that's an ancient old term that I'm re-bringing back to life, and I'm calling it clinical pathological correlation. This is the CPC way of learning. It's just been so badly fragmented, we've forgotten it, but it's the right way to learn medicine. Clinical pathological correlation. Why does your patient have a gurgle? Why are they short of breath? What are you feeling there? Well, if you do a test, what specific part of the pathology are you looking for? Testing teaches pathophysiology. CPC, clinical pathological correlation, applied over the time frame of natural history. It is the right way to learn medicine. I've been doing this increasingly more specifically for the past 10 years, and I'm telling you, it's the right way to get ready for exams, and it's certainly the right way to get ready for patient care.
Okay, so pretty attractive when I say CPC is the right way to get ready for exams. You know, the clerkship, you'll solve that problem when you get there, right? Right now, you've got to solve the problem of exams. Let's talk about the Step exams. You know, no one but the Step people are there to talk about the questions, but you know, I've taught a lot of you, and a small portion of you call me after the exam that I've specifically taught you for, just to talk about how my teaching went. I never ask about specific questions. Wouldn't remotely help you. There's a gazillion of them. But I can promise you this: the spirit of the Step 1 exam is this: clinical medicine is built on a foundation of basic medical sciences. What does that mean? It means they're starting with a patient, clinical medicine, and they expect you to say why. So if you're short of breath, why are you short of breath? In congestive heart failure, it's because you have pulmonary edema that gives you a diffusion defect and it gives you a VQ mismatch. I guess we're pretty deep in the weeds of basic sciences, aren't we? They're going to ask you questions in such a way that they don't want to know that you've memorized them. They want you to know, "Why do they work?"
Here's an example. So let's just do lung. I'm teaching some students lung. Now happens to be at the institution I'm at. So these are, count, last week I did this. This is completely true. I offered this course for these 200 students. I'm gonna show you how you need to know histology to understand lung disease. If you come and listen to this lecture, your whole course will make great sense to you. And out of 200 students, I got two. Well, two is enough for me. I love teaching. And so I went through talking about, "Why do you think that's true?" And you could see them slowly start to internalize this idea. Why, when you have emphysema, do you breathe like this, slow and with pursed lips? Do you have a mental image of the structure underlying that? Because they all do. That's a basic science mental image of lung and its pathology, correlating specifically to that patient. So those two students are gonna have a really happy course. But I promise you, everyone else will go to First Aid and UWorld and they'll plug away, going, "This is unpleasant. I wish I could see patients." Well, I'm gonna start you with your shortness of breath. When you read the stem in your questions, you'll go, "I can feel the mind of the examiner. She's talking to me. She's saying, 'I have a patient coming in, and they breathe like this. What do you think happens in their lungs?'" That is the spirit of the exam. Clinical medicine is built on a foundation of basic medical sciences, and it's a really easy way to study. You just keep asking, "Why am I learning this?"
And so, true story, I was teaching with this preeminent immunology, microbiology educator, and you know, we were really close friends. We taught all over the world together. And she was staying at my house, and we were sort of going through our curriculum of joining each other. She went into this long, complex discussion of immunology. I'm sure you've been through many of them. And I looked at her and said, "You know, I'm just not gonna learn that." And she was shocked. I mean, "I'm the expert. You have to know something." You know, it just looks like a lot of work, and I, I just don't see the benefit of it. And she will tell you that was when her whole teaching philosophy changed. 20 years she's been teaching this, right? And she suddenly went, "Oh my goodness, I'm teaching doctors, not immunology, microbiology." And so she coined this phrase. We use it all the time, and it's perfectly true: #MakeMeCare. So as you're studying, #MakeMeCare. Ask yourself, "How does this make me understand my patient better?" Clinical pathological correlation. And I promise you, that is the spirit of the Step 1 exam. And for all the tension and high stakes, you kind of start enjoying your questions more.
So, as you can tell, I, I've done lots of different teaching. I've taught classic medical schools in the Caribbean. I've done pure Step 1 prep for many years, and now I'm actually with a traditional medical school, and they are teaching exactly the way I was back in 1972. They start with a little introduction, and then they go straight to subjects, right? I mean, you've done it, right? It's anatomy, histology, physiology, microbiology. That's their first year. And then they come to second year where they're supposed to do the clinical integration of that, and then they go to clerkship. Got it. We all do that. The other variant that you see in this might be your school is, we do it by system. So we're gonna do cardiovascular, pulmonary, renal. But if you go take a look at how those system-based are done, they took each chapter from the subject and put it into that organ. In other words, you still have whoever did the PhD of lung physiology in the physiology course, just takes his lung physiology and does it in lung. It's still fragmented by subject-based experts. And this is how you can tell when you get that clinical person coming in to talk about lung disease, does she teach the physiology? Because if she doesn't, you know what you're saying, "Well, thanks, PhD, but my clinician didn't need it." So this is just for exam. If you, as a practicing physician, don't need that basic sciences, then you don't need it. So don't teach it. There's a lot to learn.
Well, you can imagine my increasing frustration, right? I'm using these physiology books, and I go, #MakeMeCare. I don't. I've spoken to lots of pulmonologists. They just don't need it. They memorize what they had to for their exams, and then dropped it. They do what they do in practice. All you're gonna get from me in clin path correlation in each system is what you have to be able to do to understand disease and its treatment. Every time you're studying, #MakeMeCare. But "make me care" is what practicing doctors do. That's a clinical subject, and it doesn't exist. So I had to write the book. And look at its title. What else could I call it, right? It's Clinical Pathophysiology. #MakeMeCare. Clinical medicine is built on basic sciences. Every system starts CPC and then goes to structure-function because we start with the patient. It's patient-centered learning.
If you haven't already, be sure to subscribe. Each week, I'm gonna be doing a new podcast, and we're going from these basic discussions to more specific things like test, Step prep, how we use testing to teach path of fizz. I'm gonna be talking to former students. I'm gonna be talking to the very small handful of educators who have moved over to the CPC style of teaching, what that feels like, and how their experience in teaching who has been. So I hope you'll tune in. If you like this video, my previous video was on the idea of completeness. See you next time.