>If you don't have a knowledge base, you simply can not practice medicine because you don't understand how things actually work...

Nonsense. Why does a heart surgeon need to know anything about psychiatry? What does a radiologist need to know about cellular biology?

The equivalent for programming would be forcing someone to understand how transistors work at the atomic level, CPU architecture, and OS structure before letting them write a webapp. It's definitely one of the problems in medicine. There's way too much useless knowledge required leading to a limited supply of people being able and willing to master it. Plus, it makes it much more expensive and time consuming to train all of those people.

Knowing about CPU architecture and OS structure helps me to reason about the application code I write. Do I understand those things as much as someone who specializes in them? No of course not. But a certain level of baseline knowledge does have its benefits.

Baseline? Sure. But that's not what med school is. It's the equivalent of a masters level course on a dozen different topics.

Medicine is more complicated than computing.

Is it?

They seem to follow a pretty similar career arc. If you take a typical CS grad they're going to go through a couple years as a junior dev, couple more as a more senior one, and then five years or more in they are ready to be in charge of their own project. That's pretty similar to the intern -> resident -> attending pattern that doctors follow.

Honestly, the biggest difference between having a career in programming and being a doctor is the gate keeping. In programming, you can drop out of high school and 20 years later be an expert in the field. There's a path for talented people to go from junior -> dev -> senior -> lead -> principle -> whatever. There's no path like that in medicine. Sure, as a nurse you can go from LPN -> RN -> NP but that's where it ends. Your only option at that point is to spend 4 years and hundreds of thousands of dollars. And there's really no reason for that.

They’re not directly comparable topics like that. A doctor definitely needs to know more than a computer scientist. But all of medicine compared to all of computer science is not an easy comparison to accurately make, since they’re both such broad topics - in medicine, everything from psychology to pharmocology to genetic engineering - in computer science, everything from transistors to complex mathematics to artificial intelligence safety. They’re both topics that are impossible for one human to understand in entirety, but society requires doctors to know a lot more of medicine.

>Why does a heart surgeon need to know anything about psychiatry?

Heart surgeons have patients with psychiatric problems. And patients are typically on psychiatric medications, which have cardiac side effects.

More broadly, heart surgeons are also general surgeons, and some psychiatry base knowledge is necessary to understand their patients.

Heart surgeons don't have to be psychiatrists, but they need some knowledge in it, which is why it's a 4 week rotation in medical school.

>Heart surgeons have patients with psychiatric problems.

Which they don't treat. That's why we have psychiatrists.

>And patients are typically on psychiatric medications, which have cardiac side effects.

Which is something a cardiologist should know. Knowing which mental illness they treat and how it does that isn't relevant.

Compliance with medication regimes and followup care can affect outcomes in cardiology, as in other areas. Understanding a patient's psychiatric illness, psychosocial functioning, and other factors can help predict treatment compliance. That in turn may influence the treatment regime the cardiologist recommends.

Medications that are prone to abuse, ones that may be more complex to take, ones that can be dangerous if someone takes too many... all are things the cardiologist should be aware of which takes some basic psychiatric knowledge.

There are few in cardiology, but many physical health meds can definitely create psychiatric side effects. How do you differentiate those from an existing psychiatric illness?

There's a large body of literature that recognizes the links between cardiac care and mental health, resulting in poorer outcomes, increased system utilization and costs, etc. Saying "this is my area, that's yours" exacerbates this problem.

> >Heart surgeons have patients with psychiatric problems.

> Which they don't treat. That's why we have psychiatrists.

People with mental illness also have heart problems that need heart surgery. It'd be nice if heart surgeons had a bit of understanding of psychiatry so they can avoid diagnostic overshadowing. This is a significant problem that contributes to the shorted lifespan of people with severe mental illness.

https://meta4rn.com/2018/12/15/shadow/

How to treat heart problems in the mentally ill would be useful training for a cardiologist. How to treat mental illness isn't.

The common theme in these subthreads is that you consider your ignorance as a superior source of knowledge. That since you personally don't know about a thing, the thing doesn't exist.

It's difficult to unhorse a debating partner who refuses to allow any evidence but their own imagination.

You have evidence that cardiologists trained in psychiatry are measurably better than those that aren't?

Just let it go. You are making an apex fool of yourself in the eyes of each and every health professional reading this. It would be strictly impossible for hospitals to function based on your opinions, which is why the supporting data you are calling for does not exist. We don't pretend to program better than you do or demand solid data to support your pet language/paradigm. Have a little understanding of others for a change. You are part of the problem, not the solution. Working on that would be the real improvement.

>It would be strictly impossible for hospitals to function based on your opinions, which is why the supporting data you are calling for does not exist.

Oh nonsense. There's plenty of evidence that lower trained providers are just as effective as doctors.

Midwives are equal or better than doctors:

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD...

No difference between Nurse Practioners and Drs:

https://www.ncbi.nlm.nih.gov/books/NBK384613/

Of course we don't have studies comparing what the equivalent radiologist not because it's strictly impossible for it to happen. But because it's strictly illegal.

There's also evidence that the way doctors are trained isn't the only possible way.

Humanities and social science majors who omitted organic chemistry, physics, and calculus, and did not take the MCAT do just as well as traditional students:

https://journals.lww.com/academicmedicine/Fulltext/2010/0800...

Performance in medical school does not correlate with performance in residency:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951767/

>Just let it go. You are making an apex fool of yourself in the eyes of each and every health professional reading this

Put up or shut up. Where is your evidence based argument that cardiologists who have a psych rotation have measurably better patient out comes than those that don't. Or that a radiologist with more biochem knowledge is a better one?

Well, you clearly don't understand what you are reading. Of course there are improvements to be made. Of course we can take shortcuts. No one denies that. Same as you could bypass your shining CS degree and certifications that you are so proud of and still be a lead developer. But as they say "there is no free lunch". That is what you should be thinking about.

Or does your self-righteousness exclude that 3 professionals telling you you misunderstand could maybe have a point? I certainly earn less than you do and have no MCAT, does that make me more truthful? CRNAs also have to learn a lot about cell biology, is that also useless cruft? Something that is taught in med school is to critically review one's own reasoning!

Forget your petty certitudes and slow down. If there was an easy way to do much better, even the AMA could do nothing to stop it. I certainly don't expect to persuade you and therefore will not take the time to "put up" and brandish more useless Cochrane reviews, but you might consider the remote possibility that you are wrong. And extremely arrogant.

Instead of searching for additional academic papers, I went on to read your comment history. Now I understand better. You are the iconic portrait of the American self-made man/woman! Going on a limb, I'd say you have a high chance of being against universal care, medical abortion and other niceties. So yeah, now I can very confidently say that you are downright nefarious to your country's healthcare system. Not just to MDs. The whole shebang.

Go hide under a rock!

"No, I don't have evidence so let me insult you again"

If you feel insulted although I took great care in staying within what could still be defined as polite if strong disagreement, let me just make clear that your behaviour is par for the course. Let's also just highlight that it's the only time over this whole thread that you do not directly oppose what I'm saying :)

> Nonsense. Why does a heart surgeon need to know anything about psychiatry? What does a radiologist need to know about cellular biology?

Medicine doesn't resemble neatly modulular systems with crisp APIs. A nodding familiarity with distant specialities is required because very frequently a patient cannot be well-treated by a single specialist.

I have a psychiatrist, an endocrinologist and an orthopaedic surgeon. They all take an intense interest in what the others have investigated, diagnosed or treated. More to the point, they have enough overlapping knowledge to profit from their interest.

> The equivalent for programming would be forcing someone to understand how transistors work at the atomic level, CPU architecture, and OS structure before letting them write a webapp.

Webapps don't often come down to distinguishing between conditions which are benign through uncomfortable, disruptive, disabling up to fatal, and besides, our hardware cousins have striven mightily to hide the messiness of reality from us. Medicine doesn't have improvable subject matter to protect it in the same way.

As a radiologist, I have to know a lot about cellular biology to understand and predict the imaging manifestations of cellular disease.

You can’t just delete the baseline foundational knowledge.

>As a radiologist, I have to know a lot about cellular biology to understand and predict the imaging manifestations of cellular disease.

A given radiologist shouldn't be predicting the imaging manifestation of cellular disease. They should be using their knowledge of how known diseases or conditions appear on scans to diagnose the issue. The people that need to understand things on a deeper level are the ones trying to devise new tests or scans to expand front line radiologists diagnostic abilities.

It's pretty wild you're telling a practicing radiologist how they should be doing their job.

One of the problems with letting people in a profession set the requirements for that profession is that they exaggerate them to limit competition and increase their earnings. You end up with things like radiologists saying they need to know cellular biology. It's simply ludicrous on its face.

Radiology is a particularly egregious case. If it weren't for legal protection the profession would be dramatically different. It's obviously stupid to spend a bunch of time training them to interpret and diagnosis a bunch of different scans. Basic efficiency would be to train Person A to interpret chest X-Rays, person B to do CT scans, Person C for leg X-rays and have them spend all day doing that one thing. Instead, radiologists spend a decade learning how to interpret a hundred different things and spend 1/100 of their time on each of them.

How do you interpret an image if you don't have an understanding of what is in it?

In other words, let's say that a patient has a fever. Chest X-ray was done.

High-school educated "radiologist" sees the image. Does he understand the anatomy? The variations of anatomy? Pathological manifestations of potential causes of fever? How to exclude image artifact versus include potential sign of pathology? What about findings that are not related to fever but need to be identified, further characterised and further imaging required for follow-up? What about signs of infectious fluid versus non-infectious fluid like blood or extravasated fluid?

What about when the ordering physician wants to discuss the findings with the "radiologist"? Will that "radiologist" actually understand anything that the physician is talking about?

There is a role for AI assisting in rapid analysis of radiological studies, however radiologists can never be replaced because AI will never perform to the level of or have the same functions as a physician radiologist.

>How do you interpret an image if you don't have an understanding of what is in it?

Because you're looking to identify patterns and match them to known ones. To use an analogy, I can teach you to identify statues of Hindu Gods without teaching you anything about Hinduism. For example, to identify Ganesh you need to know that he has an elephant head. Knowing that he has an elephant head because Shiva cut his human head off doesn't really help you.

>In other words, let's say that a patient has a fever. Chest X-ray was done.

>High-school educated "radiologist" sees the image. Does he understand the anatomy? The variations of anatomy? Pathological manifestations of potential causes of fever? How to exclude image artifact versus include potential sign of pathology? What about findings that are not related to fever but need to be identified, further characterised and further imaging required for follow-up? What about signs of infectious fluid versus non-infectious fluid like blood or extravasated fluid?

All of the things you mentioned are things that a radiologist interpreting a chest X-ray needs to know. What you need to explain is why someone interpreting a chest X-ray needs to understand Organic Chemistry. And the vein structure of the leg. And the typical development pattern of a child. And the various mental illnesses a person might have. And interpret a knee MRI.

>There is a role for AI assisting in rapid analysis of radiological studies, however radiologists can never be replaced because AI will never perform to the level of or have the same functions as a physician radiologist.

No, but I could easily take 10 people, train them each 1/10th of what a radiologist studies, and have them perform just as well as 10 radiologists by routing the right stuff to the right person.

The average Radiologist does not only interpret a single modality or the same body part day in and day out (Radiograph, CT, MR, ultrasound, nuclear scintigraphy, PET, or mammography). We are prepared by our extensive residency to competently read any and all of these upon graduation. We do not interpret these in isolation; we are constantly comparing to prior studies across modalities, often across overlapping body regions. I completely disagree that barely trained hyperspecialists would be sufficient.

While specialization is coming to all of Medicine, we tend to cluster by body region/disease state, rather than by modality. This is because all of the modalities provide complementary information and you must be able to cross reference across the various manifestations of disease.

All of medical knowledge is iterative. Unlike programming, you can’t just abstract the low-level programming. The premedical curriculum provides the baseline knowledge to understand pharmacology, which is essential when trying to understand our interventions in physiology and pathophysiology. We need to know both physiology and pathophys when interpreting imaging to know how disease manifests and what is abnormal versus post therapy related change.

We have to know how referring clinicians will treat disease, and know the major complications to look out for on imaging. We discuss their treatment plans during tumor boards and need to speak the language of the treating teams so we can tailor our interpretations to be useful.

There are no easy shortcuts here. NPs and PAs are a living experiment at a shortcut, but what I see day in and day out is that the people they consult (radiology and pathology) need to know even more clinical medicine to help the inexperienced NP or PA in knowing what to do when something happens that deviates from the protocol. Many many many times I will call with a semi-urgent unexpected finding, and just get silence on the other end of the phone. They don’t know what to do, whereas on weekends or nights when I get residents or attendings, I don’t hear this complete absence of understanding.

> I completely disagree that barely trained hyperspecialists would be sufficient.

>While specialization is coming to all of Medicine, we tend to cluster by body region/disease state, rather than by modality.

These are contradictory statements. If Doctors typically go:

No Training -> Trained in everything -> Specialized in body region/disease state

You can easily go:

No Training -> Trained in body region/disease state -> Specialized in body region/disease state

So even if we assume it's not possible to specialize radiologists any further than they already are we can still cut the training time and difficulty.

>We have to know how referring clinicians will treat disease, and know the major complications to look out for on imaging. We discuss their treatment plans during tumor boards and need to speak the language of the treating teams so we can tailor our interpretations to be useful. We need to know both physiology and pathophys when interpreting imaging to know how disease manifests and what is abnormal versus post therapy related change.

No one is denying that there are things in medicine that are complicated and require very skilled people. What you describe is the end state of a fully educated and experienced doctor. Medicine is more or less the only field that makes you become that before you start working. Can you take a reasonably smart person off the street and have him designing plans to treat tumors in a year? No. Can you take that person and train them to identify normal appearing lungs vs cancerous ones in that time? Probably. And can that person learn on the job and develop the ability to design a treatment plan over the course of 10 years working? For sure. And they wouldn't learn everything taught in Med school. They would pick up only the things relevant to the job they are trying to perform.

>All of medical knowledge is iterative. Unlike programming, you can’t just abstract the low-level programming. The premedical curriculum provides the baseline knowledge to understand pharmacology, which is essential when trying to understand our interventions in physiology and pathophysiology. We need to know both physiology and pathophys when interpreting imaging to know how disease manifests and what is abnormal versus post therapy related change.

Going back to the comment that kicked this all off. If I handed you a cellular biology final from Med school do you think you'd be able to pass it? What about the USMLE?

>There are no easy shortcuts here. NPs and PAs are a living experiment at a shortcut, but what I see day in and day out is that the people they consult (radiology and pathology) need to know even more clinical medicine to help the inexperienced NP or PA in knowing what to do when something happens that deviates from the protocol. Many many many times I will call with a semi-urgent unexpected finding, and just get silence on the other end of the phone. They don’t know what to do, whereas on weekends or nights when I get residents or attendings, I don’t hear this complete absence of understanding.

Every other field has the ability to take inexperienced people and make them experienced. There's no reason medicine can't do the same. Your clueless NP and PA should have more experienced people to go to for help when they experience something new. The next time they get that call they wouldn't be as clueless.

What you are describing is literally how medical training works. Residency IS on-the-job training. Medical school provides the foundation to then learn on-the-job; residency transitions them with graded responsibilities to independent practice.

As far as your targeted questions, yes, I do think I would pass a cellular biology test from medical school. I wouldn't get 95%+ but I would expect myself to get at least 80% correct.

I'd estimate the overwhelming majority of practicing physicians would pass the USMLE if they took it cold. They probably wouldn't do as well as they did after many weeks of dedicated study, but they would be above the minimum threshold.

>What you are describing is literally how medical training works. Residency IS on-the-job training. Medical school provides the foundation to then learn on-the-job; residency transitions them with graded responsibilities to independent practice.

It's not because you can't start on the path without going to medical school. And you don't need medical school to start learning radiology. I messed up my elbow in high school. They showed me the x-ray and said this is a fracture, this is a chip, etc. It wasn't difficult to understand and with enough time and practice I'd be able to see them in other x-rays. I don't see where something like Organic Chemistry comes into play.

>As far as your targeted questions, yes, I do think I would pass a cellular biology test from medical school. I wouldn't get 95%+ but I would expect myself to get at least 80% correct.

So ~20% of what you learned in cellular biology isn't needed as a radiologist assuming you only remember what you've actually needed.

There are a thousand reasons why your theories make absolutely no sense at all in the real world. You also make baseless and downright false assumptions due to your complete ignorance. People like you are part of the issues that make the job harder than it should be. Maybe you could take a break and re evaluate whether you have the elements to make judgement calls? Or enter med school and see if your theories hold water?

You “could” teach a high school student all aspects of medicine, but it’s going to take so long for them to build the groundwork that by the time they can meaningfully contribute, you’d never make the return on investment. This is actually how medical training was done in the years prior to the Flexner report.

From what I can tell in this exchange is that you have an innate distrust of credentialing, because you think because there is some excess therefore the entire system is wasteful. I’d argue that this is the DunningKruger effect in action.

And claiming that 20% of cellular bio is unnecessary is a silly metric when in the US 70% is passing... I don’t think that logical conclusion applies.

Yes we have more tools to look up information that we have forgotten, but as another poster here says “we aren’t bootstrapping the search each time”. If there’s something we’ve forgotten, it’s much more effective knowing where to start the search.

I agree there’s a lot wrong with our current training paradigm; the cost of medical school education is #1 with several terrible downstream effects.

However, there are no shortcuts. You have to put in the time to master the material, else you are doing your patients a disservice.

>From what I can tell in this exchange is that you have an innate distrust of credentialing, because you think because there is some excess therefore the entire system is wasteful. I’d argue that this is the DunningKruger effect in action.

>And claiming that 20% of cellular bio is unnecessary is a silly metric when in the US 70% is passing... I don’t think that logical conclusion applies.

You're saying that you don't know 20% of cellular biology that they teach in med school. You are a practicing radiologist. Therefore, 20% of the cellular biology they teach is not necessary to be a radiologist.

I have certifications in my field. Developer, Senior Developer, and Lead Developer. If I were to retake the tests, I'd get a 100% on the Developer and Senior one without studying for a minute. Those are good tests. They reflect what you need to know to be effective. The Lead one isn't. I'd probably not pass if I took it today even though I've worked several years as a lead developer since I passed it. So despite actually working in the field and becoming a better developer I'd do worse on the test. That means it is a bad test.

So when you say that the overwhelming majority "wouldn't do as well as they did after many weeks of dedicated study" that makes it a bad test. It means that a good chunk of it is meaningless hoop jumping irrelevant to practicing physicians. A competent practicing physician should breeze through a well designed certification exam.

>I agree there’s a lot wrong with our current training paradigm; the cost of medical school education is #1 with several terrible downstream effects.

>However, there are no shortcuts. You have to put in the time to master the material, else you are doing your patients a disservice.

If someone who wants to be a geriatric doctor skips pediatrics I don't see the disservice. Or take someone like a registered Nurse Midwife. Someone with 20 years experience delivering babies. The only way for them to become competent to prescribe pitocin, antibiotics, or use forceps is 4 years and $200k worth of school? It doesn't pass the smell test.

> It's simply ludicrous on its face.

That's not a meaningful test of correctness.

Many medical practices are organised as you describe (for example, surgeries specialising in nothing but hernias), but medical cases often transcend simple boundaries and a broad amount of understanding is required to detect that boundary violation (such as realising it's not a hernia, or that an organ near the hernia seems to be diseased, or that the patient is going into anaphylactic shock because of a surprise reaction to anaesthetics, or ... or ... or ... or ... ).

> or that the patient is going into anaphylactic shock because of a surprise reaction to anaesthetics, or ... or ... or ... or ... ).

And if I go into anaphylactic shock during my hernia surgery should I be grateful that my surgeon did a Pediatric, OBGYN, Neurology, Psychology, and Oncology rotation? Or that they can draw the Krebs cycle?

The level of aggressive ignorance displayed in comments like this is quite shocking. I'm puzzled as to why engineers and developers think they're qualified to give advice to other professionals in fields where they have no education or experience. What causes that type of hubris?

How does the brain work?

Okay, that was sarcastic. But in my view no doctor knows all of those subjects in depth. Pre-med students take the basic STEM courses in order to pass their MCAT's, and then forget most of what they learned, and those courses were all just superficial intro courses anyway.

To be fair, the same can be said of most engineers.

Many med students (wisely) major in a STEM subject, so they may get into more depth than someone who majored in some kind of "studies." But what they know is a function of what they actually studied, learned, and kept up with after college, which does not make me super optimistic.

Since you haven't been through medical education and training, you wouldn't understand that while certain details are forgotten, the core knowledge that serves as the basis for further learning is retained.

Do you remember every detail of your first grade education? Probably not, but it has served as a foundation for everything else you learned in life. How do you learn calculus if you don't learn numbers and letters?

You are way overstating the knowledge of most practicing physicians. You are right that most of them learned about these topics at some point, but have quickly forgotten them. I worked with a pediatrician who works in under privileged areas and conducts public health research and she had forgotten the difference between a diploid and a haploid cell (for anyone not bio savvy this is bio 101) yet she still does a fine job treating patients and understands the problems of the communities she works in.

Different people have different strengths and collaboration is all about enabling others to use their strengths. You do not need to learn most of the things on your list before you can make a positive contribution to medicine. Your list would exclude most physicians from contributing.

Yeah, med school/boards require you to memorize some trivia about some or all of those fields. That doesn't mean such knowledge is clinically useful. By necessity, most of that knowledge will be superficial because there is far too much to cover. The stuff that's useful will be retained, while the rest disappears.