Anatomy, Back to Basics

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G'day all,

Have had a student in recently, and not being far out from univesity myself, it made me think back to my undergraduate days, and how they differed from my postragduate study days and my clinical practice. Specifically, I thought about my clinical reasoning and diagnostic skills, and how they've changed and developed.

Back when I was studying biomechanics, dermatology, pathology etc. at an undergraduate level, it was all about rote learning; 'Tibialis posterior dysfunctin is characterised by an excessively pronated rearfoot and medial bulging at the ankle'. When I first started practicing, it was still like this. Patern recognition with reference back to all the information I had rote learned. Which was great, until I got a case that was beyond the 'normal' concepts I had learned. Then it became a game of hit and miss, trying to work out what was going on and how I could fix it. The student I had recently was still very much doing this. We had a patient with a sore heel, with pain located over the medial tubercle with direct palpation, no gross biomechanical deformity and no apparant aetiology, but was sore first thing in the morning and had been present for about 2 months. My studnet quickly came to the 'heel spur' conclusion, as we all have done. Which is all well and good, fits the pattern, sounds about right. I then pressed him for 5 differential diagnoses for the pain in the same region, with similar presentations. We had hit a wall.

The way I began to think him through it was simple, a concept I had picked up in adult learing whilst doing post grad. Make it simle and break it down. The simplest form in the body is the anatomy, and the related physiology. I got him to list all the anatomical structures in the area, and the physiological actions of these structures. Then we took these, and worked out what could go wrong with each structure, and how we coud diagnose, or otherwise, each of these pathologies to each of these structures. All of a sudden we had a great 'bigger picture' of what was going on. From there, we could find strategies to deal with each of these diagnoses. We had a diagnosis, and a treatment plan.

Sounds simple doesn't it? But really, how often do we do this? Patten recognition is so simple, and more often than not, we're correct, but for those few who don't respond, we become unstuck. I know, it happends to me too, I fall into pattern recognition and get stuck too! I put forward the challenge to everyone, take a look, break down the anatomy, see whats there and what it should do, and from there work out what can go wrong with it. Helps to make us better diagnosticians, formulate better management plans, and get better results with out patients. Better Clinicials overall really! (Also works great for understanding biomechanics too!)

 

G,day Adrian,

Just need to agree with everything you say. There's 'rote' learning and the bigger picture. A good clinician must try to see the bigger picture and think out of the box. But the underpinning knowledge is very important. This ability to see the bigger picture comes with using the knowledge, practice, experience and just plain 'sleeping on it'.

However, students can be told that this will happen and helped to see the need to learn as much as possible to form the bigger picture.

But anatomy and physiology are not enough in themselves. Pathology/clinical skills are also vital, along with a great number of other underpinnings.

Students taught by rote alone are much less likely to shine and will take longer to properly understand that which is presented to them. I suspect that many never make this transition to big picture thinking, or see it as important.

Regrettably, there is teaching and there is learning. You can teach for all you are worth and to the best of your ability but the other half of the contract is that the student must employ mature thought process to the knowledge delivered. A good teacher will constantly demonstrate how the basics are employed.

It seems to me that mentoring is something that should be built in to learning at undergraduate level and that it is wasteful to apply such mentoring only when we have acquired the rote knowledge. How to use the knowledge should be a greater part of the students evolution.

 

Excellents thoughts Adrian!

I had a physics teacher in high school who would always tell us "to learn from first principles". Whether you are lerning anatomy, biomechanics or learning to kick a football. You can learn the global action ie. kicking the ball. Or you can break it down into fundamental movements. the later option will always take a lot more time and effort to accomplish, however it will benefit the player in the long term as these fundamental movements can be applied to other elements of the game, rapidly improving skill aquisition in later stages.

The same can be said for podiatry. If we learn the "patterns"and symtomology of a condition it will help us get trough an exam at uni with minimal time and effort. If we take the time to learn all about the anatomical structures involved in the same condition ie. muscle attatchments, nerve supply, possible anatomical variations, functional role in gait etc etc. We may get the same result in the exam, however the long term result of learning the fundamentals will allow us to deal far more effectively with ay curve balls that may get thown our way.

my thoughts

Luke