Liyang Pan: Medical education—the tyranny of guidelines and the single best answer

Simplification has a place in medical education, says Liyang Pan, but shouldn’t be at the cost of teaching students about medicine’s complexity

After years of running the gauntlet of exams, drilling various clinical scenarios with my peers, and poring over seemingly bottomless question banks, I graduated from medical school. My medical school, like most in the UK, exposed us to a variety of specialties within a short space of time, and relied on a pool of multiple choice questions and a few clinical scenarios to test each cohort at the end of each year. Material was condensed to fit this format and complex issues were reduced to more manageable headlines. Consequently, I have been instilled with the idea of a single “right answer” and a “correct thing to do,” rather than the murky grey reality of a few “possible right answers” and “potentially good things to do in something similar to this situation.” This is not only unrealistic, it also stifles discussion and debate. 

The focus of medical education is now rote learning national guidelines, with few caveats or critique. Thorny unresolved issues become a single line on a page to memorise, with little elaboration before or after. The concepts of ambiguity or the unknown within these pages were not introduced to me or my peers. Students, myself included, use a combination of acronyms and aide memoires rather than understanding that guidelines are recommendations or questioning their underlying evidence. 

When the guidelines for asthma management from the British Thoracic Society and the National Institute for Health and Care Excellence were published, there were some key discrepancies in the diagnosis and management algorithms. In stuffy libraries across the country, we wondered which one to memorise for exams rather than discuss the merits of one or the other. My clinical years were largely filled with piously memorising recommendations such as these, which were considered a series of manifest “facts.” There was little acknowledgement that “these are the guidelines, but really it’s still up for debate.”

This issue is illustrated by the diagnosis and management of sepsis, and its effects reach beyond university examination halls. Medical students faced with a doctor asking them about sepsis have a set script, which is adapted from the Surviving Sepsis Campaign, and any deviation results in loss of easy marks: 

“Sepsis is diagnosed when two of the three qSOFA criteria are fulfilled. To manage, start the sepsis six within one hour. Take three and give three. Take blood cultures, urine output, and lactate. Give fluids, oxygen, and antibiotics. Call a senior.” 

This patter is embedded in the minds of medical students up and down the country, with the nifty acronym of BUFALO attached. Yet, in my time at university, there was no conversation considering the quality or existence of evidence supporting the use of qSOFA over SIRS for diagnosis, the one hour window for treatment, lactate to assess response, or the correct amount of whichever fluid to resuscitate patients. Rather than acknowledge that there may be other ways to skin a cat, or that not everyone thinks skinning cats is a good idea, or that we should maybe think about skinning dogs, the sepsis six protocol was the only way to treat sepsis. 

This blanket totalitarian approach and the oversimplification of a complex condition, which still has many unknowns, has also seeped into government policy and the public domain. Cash strapped hospitals are dependent on reaching the government sepsis targets for funding. News reports and court cases have been built, and public trust has been eroded, by the perception that if the above protocol is followed sepsis can be definitively cured, and not following the protocol will lead to avoidable complications.

Simplification has a place in communicating medical knowledge. It is necessary to accommodate breadth, and groundwork should be laid before detail is learnt. The practise of medicine is impossibly intricate, requiring years of experience and learning, while guidelines are constructed by expert panels amalgamating mountains of (often conflicting) evidence to improve and standardise care. However, by not communicating that this knowledge is vastly simplified or potentially inaccurate, it becomes disingenuous and prohibitive. Bright inquisitive minds lose their propensity to challenge and to question, quashed by the onslaught of dogma and “facts.”

Perhaps it is ego or insecurity that prevents the words, “We don’t know, it’s a bit complicated,” from leaving doctors’ lips and landing in the ears of medical students or the wider public. In reality, I suspect that there are others, like myself, who would appreciate honesty rather than a falsely definitive answer.

Liyang Pan is a foundation doctor at University College London Hospitals Foundation Trust.

Competing interests: None.