Information explosion blows up traditional concepts
Graduate medical education (GME) is far different today than it was 20 years ago. Societal, financial, and regulatory pressures—as well as a new generation of residents more focused on quality of life—have led to significant changes in how physicians learn. Although both residents and educators often discuss these influences on education, they frequently overlook today's resident learning style, in particular the impact of information overload and instant access to electronic media.
When the number of accepted medical texts and journals was limited, most accepted knowledge on a topic was confined, and the task of locating and reading "important" information was quite easy. Today, however, thousands of medical papers and books are published yearly, numerous websites are updated daily, and webinars are constantly being published, making it impossible to keep up. The most relevant information on any given topic has exploded, scattering concepts, facts, and ideas everywhere.
Today, more knowledge about orthopaedic surgery is available than ever before. But what are the best ways for residents to find and synthesize this information? More importantly, do today's residents have a greater mastery of orthopaedic principles and are they more prepared to go into an orthopaedic surgery practice because of all this information?
Popular review sources, such as the AAOS Comprehensive Orthopaedic Review, www.orthobullets.com, and Miller's Review of Orthopaedics, cater to the resident's need to keep abreast of this plethora of data. These and similar books, podcasts, lectures, apps, and websites are designed to help residents obtain the most important information on a topic while expending minimal time and effort internalizing it. These sources differ significantly from review articles published in the Journal of the AAOS and Instructional Course Lectures because they do not provide substantial depth in the topics they cover.
Although residents can still choose to read a textbook chapter or a journal article, many trade an in-depth 50-page chapter for a webpage or book section that can be scanned in 50 seconds. There seems to be a generational view that quick references provide residents with knowledge that is "good enough"—even if it excludes critical context or insight.
Time constraints may foster a pattern of finding an answer, memorizing it, and repeating the process when the same question is asked again. The initial investment for short-term memorization pays off, even if the long-term dividends of true comprehension are unrealized. The effects that these trade-offs may have on patient care remain unknown and are often not contemplated.
Many residents do not realize that review sources may promote learning in a way that is inherently different from focused reading of a book or journal article. Review sources present facts simply and succinctly, without much explanation or perspective, because they are designed primarily to help refresh residents' comprehension of material learned in great depth previously, rather than as the primary information source.
The brain seems to form connections and memories at a rate proportional to the effort invested in learning or remembering a topic. Some evidence indicates that reading a book leads to increased retention of material compared to reading from a computer or online source.
How information is processed matters. Reading about a topic for an hour without distraction is more likely to result in recalling basic principles 2 weeks later than repetitive skimming of that topic over 5 to 10 minutes for short-term memorization. The more in-depth the understanding of the basic principles of a topic, the easier it will be to translate and use those principles for an altogether different topic.
Considering the goals of review resources is also important. Although they provide useful information, they are meant to be profitable endeavors for the publisher. Multiple updated editions are published that offer exclusive access to even more material. Ironically, although these resources advertise condensed reviews, their ongoing growth due to the increase in medical data results in a large volume of facts without the context that may actually aid in comprehension.
The debate over mastery
Some experts argue that today's surgeons no longer need a fundamental mastery of every diagnosis or procedure. To attract patients, they say, surgeons must be skilled technicians, able to navigate available resources and promote their practices on social media. A physician who relies on a reservoir of fundamental knowledge cultivated by life-long learning may not deliver the instant gratification that patients demand.
Such an approach, however, may result in surgeons who are technical experts, able to follow directions to accomplish a task but unable to produce original work or apply foundational principles to fluid or unexpected situations.
Competency cannot be defined simply by test scores or similar metrics. At the end of training, resident physicians must be capable and, more importantly, competent for the independent practice of medicine. Focusing on review sources that may improve test scores and provide "just the facts" does not provide the comprehension of concepts necessary for optimal patient care.
In a world in which evidence-based medicine is the gold standard, there seems to be very little evidence-based education. When almost all residents have access to the same information simultaneously, why do some demonstrate far greater understanding of the material than others? What different learning habits facilitate comprehension?
Although the 80-hour workweek or lack of motivation may be partly culpable for some issues in physician training, it would be naïve to ignore the impact of electronic media and review resources. The explosion of information has changed how we learn and, therefore, what we learn.
Although finding knowledge was once the rate-limiting step in learning, today, the processing and synthesizing of the massive amounts of data available limit learning rates. Unfortunately, understanding how and where to learn is difficult and rarely taught.
We, as surgeons, would never assume that residents can perform an invasive procedure without first being supervised by those who are skilled in that procedure. A similar philosophy is necessary for instructing residents on their learning skills. Considering the amount of educational information available, the value of any one piece is exceedingly low. Certainly review resources and electronic media are valuable to medical education but, as a profession, we must consider their impact on training and patient care. Most importantly, educators must ensure that residents use and synthesize knowledge from the most appropriate sources, not simply those that are the most accessible.
Chad A. Krueger, MD, is the current Resident PAC Fellow. He can be reached at firstname.lastname@example.org. Matthew R. Schmitz, MD, is the assistant program director at San Antonio Military Medical Center. Patrick M. Osborn, MD, is the orthopaedic surgery program director at San Antonio Military Medical Center.