Jan 25, 2014

The preclinical years of my medical school were wholly focused on mechanisms. The goal was to teach medicine from first principles. Consequently, my professors were not medical doctors but were renowned researchers in physiology and anatomy. The first 200 pages of our renal course book summarized tight junctions down to molecular details. The first 100 pages of our cardiology course book taught resting membrane potentials by making us calculate it using Gibbs free energy. I remember feeling frustrated at the level of minutia and asking: “how is this possibly pertinent to clinical medicine?”

The teaching strategy in my clinical years was the exact opposite. My professors were all medical doctors who taught top down rather than bottom up. I learned to manage hypertension based hypothesis driven experiments: ACCOMPLISH trial, A-HeFT trial, ALLHAT trial, CONSENSUS trial, and COPERNICUS trial. One could never escape minutia in medicine. In lieu of Gibb’s free energy, I unwittingly entered a world of acronyms. And I hate acronyms.

I was learning clinical medicine and it was like drinking from a fire hydrant; millions of seemingly random facts pouring in from all directions. I found myself trying to remember names, dates, and journals of trials I had never read as a means to justify clinical decisions I did not fully understand. At the end of the day, I had garnered very little actual knowledge. Most of it ebbed away into a large puddle at the bottom of my feet.

It was impossible for me to learn in this way. I preferred to contextualize rather than memorize. The physiologic concepts taught in my preclinical years formed context. It allowed me to build a rational ladder to the right answer; a ladder I could reconstruct every time. Physiology, for me, made sense of the voluminous topic of medicine. As my appreciation for my preclinical years grew however, my memories of those seemingly impertinent mechanisms and pathways faded away.

This website is my attempt to relearn medicine, not top down or bottom up, but from the middle: an admixture of physiology and EBM punctuated by the commentaries from a distractible mind.

Jan 25, 2017

Three years after starting this website, I reflect on its progress and in turn reflect on my own. I had hoped to find and provide a list of landmark articles in emergency medicine and critical care that would form the backbone of instruction, learning, and patient care. Unfortunately, this holy grail does not exist. Unstable patients and resuscitations are almost impossible to study in a randomized or controlled fashion. The feedback loops are too short; there are too many actions and interventions; the population, disease, and treatment are too heterogeneous. And most importantly, resuscitation is the search for a miracle - an outcome that defies an average. Statistical methods will never beat an astute clinician grounded in physiology in finding the ideal concoction to achieve an outlier.