Dr. Vimla Patel PHOTO: OWEN EGAN

Disentangling the cobwebs in medical education

PATRICK McDONAGH | Dr. Vimla Patel has an uneasy relationship with established truths: she just doesn't trust them. Patel does not give off the aura of an inherently cynical individual. Rather, Patel's challenges to conventional beliefs seem to stem from an energetic (almost exuberant) desire to get underneath orthodoxies. No one can call Patel an underachiever. The director of the Centre for Medical Education in the Faculty of Medicine, Patel lists the areas she hopes to profoundly alter: how medicine is taught in universities, how medical information is transmitted across cultures, how international bodies like the World Bank assess and respond to educational projects in developing countries, how computers are integrated into the patient/physician relationship. In fact, the multi-disciplinary Patel's entry into a field seems a fair guarantee that people will not perceive it in the same way again. Consider her work analyzing the articulation and transfer of medical knowledge. Patel sought to create a model of how physicians come to diagnose patients -- essentially, she wanted to model medical knowledge and decision-making. She recorded practitioners in a number of environments -- from manufactured situations to real-life clinics -- to collect data on how doctors talk about medicine with patients and with each other. Take the proposition that "infection" causes "fever," for instance. "Infection" and "fever" are both concepts whose relationship is one of causality, so the phrase in total forms an "idea unit." Patel's analysis involved breaking down medical discourse into these idea units, measuring their coherence, and analyzing how these idea units became layered on top of one another, creating a semantic network. What she found was that medical practitioners communicate at different levels of discourse, depending upon their position in the field. Specialists communicate at a sophisticated level, collapsing idea units together into more complex and layered propositions, general practitioners at a less complex level for a given diagnosis, and medical students at a relatively simple level. At each level, analysis, comprehension and decision-making are taking place; between levels, one must exercise an awareness of how knowledge is transferred in order to communicate successfully. These findings become useful when trying to develop a medical curriculum. At McGill, medical students were given a traditional education which stressed the accumulation of scientific information that would later be applied in a clinical context. Meanwhile, some other medical schools, such as McMaster's, based their curriculum on "problem-based" learning: students learned about science by considering it in the context of particular clinical problems. "Problem-based learning is appealing to students because it brings relevance right to your doorstep. It's a very sexy idea," agrees Patel, but she felt it hadn't been investigated thoroughly to determine how well it worked. After a joint study with McMaster, analyzing the difference between diagnoses made by McGill and McMaster medical students, she discovered that while problem-based learning helped students to relate science to their clinical activities, it hindered their ability to generalize. "It was too context-based," she explains. Diagnoses were "hypothesis-driven": students were learning, but not asserting their knowledge. In contrast, McGill students could make confident "data-driven" diagnoses in the manner of expert physicians. "What this means," explains Patel, "is that the problem-based strategy provides a good environment for learning, but doctors also need the professional confidence to come to closure. In medical schools we're certifying competence; patients want diagnoses." Both McGill and McMaster have since adapted their curriculum to include a mix of problem-based and traditional learning. "If classrooms teach only what you do in the real world, they're giving information that is too contextual. This doesn't mean that we shouldn't teach realistic tasks, but that we need to prepare people to think abstractly in the real world, to become general learners." And there is no time for sitting still. "We need to evaluate new curriculum constantly," she asserts. Patel herself is a good example of someone who has mastered the idea of transferable skills. From analyzing medical decision-making she has segued into studies on attempts to convey health and medical information across cultural barriers. "We have to understand how people reason about health and disease based upon their traditional knowledge if medical education is going to have any impact," she notes. Indeed, medical knowledge is often simply incompatible with indigenous systems of belief: there are two parallel models of interpreting health phenomena. "So," she notes, "although we try to teach doctors to be more 'sensitive' to cultural beliefs, often information just cannot be integrated. You need to sensitize doctors to this issue, but ultimately they have to treat the patient and get on to the next." Patel began her academic career as a biochemist. Eventually, she found herself confessing to Hugh Scott, then director of the Centre for Medical Education, now overseer of the McGill University Hospital Centre, that she wanted to do something to help teaching in medicine. "Good idea," he responded, and directed her into McGill's educational psychology program. Patel was an enthusiastic beginner. Since she had no background in educational psychology, she found herself taking undergraduate courses, but began graduate courses simultaneously. She had an undergraduate degree in 1978 and, by 1981, was polishing off her doctorate. "I couldn't wait to adjust to the system -- it had to adjust to me," she explains. "Rules are like cobwebs: you get entangled by them." Patel has become adept at disentangling cobwebs. Her groundbreaking work analyzing medical decision-making has captured attention in fields outside of medicine. She has been conscripted by the World Bank to examine the process by which their economists made decisions on projects in developing countries. Why were so many initiatives unsuccessful? "One of our critical findings was that the nature of training provided at the World Bank did not relate to what people did when they negotiated and solved conflicts in terms of cultural difference. Cultures deal with economic issues differently. Therefore you would see premature closure of projects," she explains, also noting that the bureaucratic tendency to stick to the safe side was not always compatible with local notions of risk-taking. The World Bank's economists were responding to what they understood to be happening, but not to what their clients in developing nations perceived. The work by Patel and her McGill team will be integrated into a new training program for World Bank staff that will be offered at the University of Pittsburgh. A member of the HEALNet Network of Centres of Excellence, Patel is working on another study concerning how patients understand and acquire information about their medical conditions. For instance, the Internet is becoming a hugely popular resource for patients doing research. The implications of this are important -- are patients gaining a more sophisticated understanding of medical issues or are they being steered in the wrong direction by bad information (or by misunderstanding the information they come across)? "We must take into account how that information is understood, who is trying to understand it and what problems occur in comprehension and application of that information," says Patel. What sorts of patients go hunting for data in this fashion and how are they drawing conclusions from it? Getting a better handle on these questions, says Patel, will help health care specialists develop appropriate computer-based information systems that will facilitate understanding. Issues of perception and interpretation -- data and theory -- are critical to Patel. By the door to her office in Lady Meredith House is a board on which she writes a "quote for the day." Today's words of wisdom come from Anais Nin: "We don't see things as they are; we see things as we are." Vimla Patel's work takes Nin's aphorism to the next level: seeing ourselves seeing things as we are.