Approaches to Learning in Medicine:

Top down and bottom up learning

“Top down is a pre-formed idea and we can choose to say yes or no. Bottom up is an exploratory idea where new direction can be woven from multiple diverse strands (many of which can be "top down"). Top down is essential; bottom up is existential. Top down relates to realist ontology - it is really objectively there; bottom up relates to relativist ontology - it is there if it is meaningful to you. Today's bottom up can be tomorrow's top down and vice versa. Top down in one place is bottom up in another.  The two are constantly (and rightly) interwoven at all levels.” Paul Thomas from the complexity in health list"

The present system of medical learning especially during formal training is more top down. Future health professionals are very often simply expected to learn and memorize the structure of their chosen field of medicine and then apply it for patient care. However a complete top down approach in present day health care is increasingly unable to support health care practice as the volume of information keeps growing by leaps and bounds. (2)

  “ Half of what you are taught as medical students will in ten years have been shown to be wrong. And the trouble is, none of your teachers know which half”

Sydney Burwell, Dean, Harvard Medical School 1956

One response of the present health care structure to this problem has been an ant like division of labor where health care workers specialize in certain areas so that they can focus on a smaller volume/area of accumulated information and thus offer their expertise in their chosen areas. There is an old adage often used to qualify this approach as, “Knowing more and more about less and less until one has known everything about nothing”.

Interestingly there isn’t much historical evidence to suggest that this approach is doing wonders to present day health care (3). On the contrary present day patient satisfaction with health care seems to be at an all time low.  

One of the important present day problems with this approach is that from the patient perspective searching the health professional with the appropriate expertise to tackle their particular individual problem becomes like looking for a needle in a haystack.

To quote an individual patient’s relative,  

“While the quality of the medical care my mother received was extraordinary, I saw firsthand how challenged the health care system was in supporting caregivers and communicating between different medical organizations. The system didn't fail completely, but struggled with these phases:

- What was wrong -- it took her doctors nine months to correctly identify
an illness which had classic symptoms
- Who should treat her -- there was no easy way to figure out who were the
best local physicians and caregivers, which ones were covered by her
insurance, and how we could get them to agree to treat her
- Once she was treated, she had a chronic illness, and needed ongoing care
and coordinated nursing and monitoring, particularly once her illness
recurred. Adam Bosworth, Vice President, Google, "Health care information matters:
http://googleblog.blogspot.com/2006/11/health-care-information-matters.html

Also wouldn’t it be much easier for patients if the large task force of health care professionals kept learning more and more about more and more (instead of less and less) and brought back the good old days of the all-knowing family physician (not necessarily all powerful) who could function as a pillar through out the whole healing process only this time the family physician would have an important check in power by the well informed patient.

The need to de-specialize

It is great to be able to have a focused “hit the nail on the head” approach. What does one do with so many hydra headed nails?

The common refrain to such ambitious proposals of knowledge/expertise accumulation by the present day average health professional/physician is immediately waved off as impossible and unsavory. Whoever heard of a physician doing echocardiographies as well as endoscopies and also managing patients on dialysis or a surgeon operating on Hirshprung’s as well as doing Cesarean sections? It may not be that 50 years back physicians knew less or had less information and expertise to cope with. What has happened with progress is that the old volume of information and expertise has simply been replaced with the new. (3) With rapid technological strides and shrinking tools of the trade, like an echo ultrasound scanner incorporated into the mobile phone and the endoscope (fit for a sword swallower) getting replaced by the capsule with a videoendoscopy unit and with the advent of tele-robotic surgery it is no longer impossible for the individual physician-surgeon to learn and expand in a multidisciplinary approach rather than a small focused area. Physicians and surgeons who could have benefited society to a larger extent with their multiple areas of expertise and continued self development with a bottoms up learning approach have largely moved by their own choice to more remote areas before they could be exiled by the increasingly dominant and territorial top down experts defending their smaller areas of expertise (backed by market forces).

Quoting from a recent email forward,

“… Physicians here are awe-inspiring. Every one here is in the process of 'de-specializing'. That does not mean that they are losing their skills as specialists. It means, they are learning the other specialties. ENT surgeon here is managing medicine OPD patients for 5 yrs and knows more about approach and management of general OPD issues than I do. A pediatric surgeon has become a general surgeon and has learnt anesthesiology and practices it when no volunteer anesthetist is available. A pediatrician is learning C-sections. Needless to say, they are all able obstetricians.
They all (7 physicians) started without any preconceived notions. Came to a rural setting and started learning how to become rural doctors. Many of my myths were shattered here in the first week itself..."

Priyank Jain, Resident Medicine, Wisconsin Milwaukee on a visit to a rural health set up run by a few committed physicians in Ganiari, Madhya Pradesh, India

Bottom Up medical learning: Need for a user driven innovation pertaining to E- learning in Health care

When we say health information for all, it is pretty much self explanatory... but in this context what I would like to highlight is the fact that the target population is not a single entity but multiple groups... some are at a better financial status, some have better access to libraries and journals, some use the internet more often, so on and so forth.
So, I feel, the first step is to define the population for which we are trying to provide the health information. In that way we will actually be able to understand
1. the needs of that population

2. find out the best means by which we can provide the information.

So in this question of WHO needs WHAT, it is necessary to identify the WHO... then the WHAT will automatically manifest.... then we can discuss about the WHEN, WHERE and HOW

Kaushik Sundar, Medical student, Vydehi Institute Of Medical Sciences, Bangalore, India. Posted to HIFA2015 www.hifa2015.org

In recent times the top down compartmentalized structure of medical education and practice has been challenged by the evidence based health care movement (before it got compartmentalized itself into a specialty) and the complexity in health care movement. Both groups have recognized the need to disseminate learning on a broader basis that bridges the compartmental divide (presently with weak forces) across the specialty structures in the standard medical model. Bottoms up learning resurged in medical education in a bigger manner with the formalization of problem based learning in the 1980s closely followed by the evidence based health care movement in the 1990s. Evidence based health care is a form of problem based learning applied to daily health care activities with a purported objective of meeting individual patient needs using the accumulated and growing epidemiological population based average patient outcome data. At present it fights a gradually losing battle to establish an absolute unchanging structure of medical truth that is generalized to all users on the basis of statistically averaged health outcomes from controlled trials.

“So what is to become of us serious medical technocrats in this postmodern age where multiple versions of the truth abound?” (4)

A useful perspective to the initial problem of health information for all, defined at the opening of this paragraph would be to look at it from a bottom up user driven approach and the answer may be, “ All humans may need to use health information and depending on their stance as a patient or health care professional their individual needs would vary and may not be answered by the average patient approach modern medicine compels us to go by.”