Quiet in the Library
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《新英格兰医药杂志》
The library at my medical school has never been a better place to work. The journals are shelved in perfect order. The copying machines have no lines. Quiet, comfortable places in which to read are plentiful. The reason: hardly anyone goes there anymore.
Only a few years ago, this library was noisy, chaotic, and often frustrating — but it was full. For the researchers, medical students, and physicians who once haunted the stacks, the need for access to information has only intensified. But an explosion of knowledge, combined with the emergence of the Internet as the ideal searching tool, is transforming medicine, with implications reaching far beyond the library walls.
The most profound change is the growing understanding — indeed, acceptance of the reality — that there is simply too much to know. A generation ago, medical students went to the library not only for the books or journals but also for a quiet place away from their stereos and telephones. Like many students of the 1970s, I was taught a simple secret to success: "You just have to learn everything." And we tried to do that, memorizing facts and flowcharts during long evenings in the stacks.
The goal was to be the resident with the richest "fund of knowledge" or the attending who could discuss any case at morning report. The names of physicians who attained such status are still murmured with awe, but most medical schools now define more realistic aims for students. Instead of futilely attempting to master everything, students now try to "learn how to learn" — how to approach situations in which they do not know the patient's diagnosis or what treatment to use.
Memorization is a solitary activity; learning how to think when confronted with uncertainty is not. Thus, conference rooms where groups of students discuss cases are now more central to medical education than library carrels. For work that is best done alone, the library no longer guarantees isolation. Even when sequestered in the stacks, students are always reachable by cellular telephone or wireless e-mail.
Once they had completed their training, some physicians used to frequent the library to stay up to date by browsing through recent journals in areas outside their specialties. Today, however, few can hope to stay current in more than one or two fields. The flood of new information and the demands of simply getting through the day have become so overwhelming that many physicians no longer find the time for "lifelong learning" through such activities as reading journals or attending grand rounds. Instead, they rely on "just-in-time" learning tactics, such as searching the Internet or tapping the expertise of specialists in order to answer questions raised by patients who are often sitting directly in front of them.
These changes contribute to the malaise felt by many physicians in the face of modern medicine. Once they were the experts. Today they cannot even stay a step ahead of patients. Physicians quietly acknowledge the loss of dignity they suffer when they no longer have time to understand completely how a new drug works or when they find themselves thinking, "Just tell me what to do."
The really painful insight for many physicians is that although they themselves know they cannot know everything, their patients still seem to expect them to do so. Patients are surprised when they ask about a drug they've just read about and their physician asks how to spell its name. Doctors are embarrassed when they hesitate, unsure of how to approach bread-and-butter problems because there are so many more options than there used to be.
In a culture in which those who wear the white coats are supposed to know everything, physicians face complex choices. Most (though not all) of them recognize that perpetuating the myth of physicians' infallibility is impossible and that it is preferable to acknowledge and address the limitations of their expertise. Any physician who does not use online or print resources or call for help from colleagues when confronted with a complex case runs the risk of not giving the patient the best possible care.
Just as the medical library is undergoing reinvention, so too is the notion of what it means to be a doctor. Although physicians cannot be all-knowing, they can still be all-caring. Such physicians may not immediately know the best approach to a patient's condition, but they will not rest until they have found it. There is real dignity in that.(Thomas H. Lee, M.D.)
Only a few years ago, this library was noisy, chaotic, and often frustrating — but it was full. For the researchers, medical students, and physicians who once haunted the stacks, the need for access to information has only intensified. But an explosion of knowledge, combined with the emergence of the Internet as the ideal searching tool, is transforming medicine, with implications reaching far beyond the library walls.
The most profound change is the growing understanding — indeed, acceptance of the reality — that there is simply too much to know. A generation ago, medical students went to the library not only for the books or journals but also for a quiet place away from their stereos and telephones. Like many students of the 1970s, I was taught a simple secret to success: "You just have to learn everything." And we tried to do that, memorizing facts and flowcharts during long evenings in the stacks.
The goal was to be the resident with the richest "fund of knowledge" or the attending who could discuss any case at morning report. The names of physicians who attained such status are still murmured with awe, but most medical schools now define more realistic aims for students. Instead of futilely attempting to master everything, students now try to "learn how to learn" — how to approach situations in which they do not know the patient's diagnosis or what treatment to use.
Memorization is a solitary activity; learning how to think when confronted with uncertainty is not. Thus, conference rooms where groups of students discuss cases are now more central to medical education than library carrels. For work that is best done alone, the library no longer guarantees isolation. Even when sequestered in the stacks, students are always reachable by cellular telephone or wireless e-mail.
Once they had completed their training, some physicians used to frequent the library to stay up to date by browsing through recent journals in areas outside their specialties. Today, however, few can hope to stay current in more than one or two fields. The flood of new information and the demands of simply getting through the day have become so overwhelming that many physicians no longer find the time for "lifelong learning" through such activities as reading journals or attending grand rounds. Instead, they rely on "just-in-time" learning tactics, such as searching the Internet or tapping the expertise of specialists in order to answer questions raised by patients who are often sitting directly in front of them.
These changes contribute to the malaise felt by many physicians in the face of modern medicine. Once they were the experts. Today they cannot even stay a step ahead of patients. Physicians quietly acknowledge the loss of dignity they suffer when they no longer have time to understand completely how a new drug works or when they find themselves thinking, "Just tell me what to do."
The really painful insight for many physicians is that although they themselves know they cannot know everything, their patients still seem to expect them to do so. Patients are surprised when they ask about a drug they've just read about and their physician asks how to spell its name. Doctors are embarrassed when they hesitate, unsure of how to approach bread-and-butter problems because there are so many more options than there used to be.
In a culture in which those who wear the white coats are supposed to know everything, physicians face complex choices. Most (though not all) of them recognize that perpetuating the myth of physicians' infallibility is impossible and that it is preferable to acknowledge and address the limitations of their expertise. Any physician who does not use online or print resources or call for help from colleagues when confronted with a complex case runs the risk of not giving the patient the best possible care.
Just as the medical library is undergoing reinvention, so too is the notion of what it means to be a doctor. Although physicians cannot be all-knowing, they can still be all-caring. Such physicians may not immediately know the best approach to a patient's condition, but they will not rest until they have found it. There is real dignity in that.(Thomas H. Lee, M.D.)