Find Andrew

Wednesday, September 24, 2008

A word on Socratic Method:
Socrates and Plato, according to Wikipedia, taught that the soul is an immortal and all-knowing force that incarnates time and time again through the life and death cycle of the human form. Though the soul itself knows everything, it's for some reason wiped clear of this knowledge every time it's reincarnated, where we spend most of our lives trying to re-learn everything we'd forgotten before we die again. Therefore, Plato would say that there's no such thing as new knowledge, there's only the remembering of forgotten knowledge.
This is why Socrates refrained from lecturing directly. Instead, he would pick on a particular student and lead them down a series of questions until the student himself came up with the information of the lecture. By never lecturing directly, Socrates could say that he was only helping the student "remember" what he had always known.

I was first introduced to Socratic teaching during my three weeks in Trauma. Three times per week, the entire Trauma unit (up to 30 people, all various levels of students except a few attending) would chose a few patients to discuss and cram into the room beside each patient, where an attending would "teach." A student would present the case:

"Here we have Mr. John Doe, came in three days ago with a gun shot wound to the left flank, along the axillary line at the 9th intercostal space."

This usually means that today's lecture will be about the management of a patient with a gunshot wound to the left flank. That's what I got used to hearing for the first two years. Here, an attending would then ask the student to stop while he looks at somebody's name tag and says "Andrew, what are the structures we're worried about hitting when a bullet passes through the 9th intercostal space?"

OK, easy. Spleen, Stomach, Diaphragm, Lungs, Liver, Heart, and just about everything else depending on the angle.

"Very good, and how would you assess for injuries to these structures?"

Not so easy. Well, I guess I'd see if he's vomiting blood, we'd know it hit the stomach.

He wants me to say we'd rule out a major arterial bleed, then order a CT scan of the chest and abdomen. Instead of going straight there, the attending would then look at a resident and ask "What is the possibility that a gastric penetration would present with frank vomiting of bright red blood?"

That's a tough question, which is why it was given to a resident. However, we quickly learn that the answer to most of these is either 20-30% or 70-80% (unless it's less than 3% or greater than 97%), which the resident would chose and the attending would probably say "Almost. It's actually.." and then he might cite a recent meta-analysis of world data that came out with whatever figure he had in mind.

Then he'd turn back to me and ask "Let's say he's not vomiting blood on presentation. What would be your first concern?"

"Bleeding, I guess"

"And how do you assess for bleeding?"

"Hypotension?"

"You're right, if the patient had a very low blood pressure you may be inclined to think he was bleeding significantly. However, you will remember that 40% of your blood must be lost before you show signs of hypotension. How would we be able to tell if there was massive internal bleeding sooner than that?"

"CT scan?"

"Very good, that would tell us for sure whether he's bleeding, but you might not want to subject a patient to an hour-long CT scan if he's bleeding internally. Any other ideas?"

I'd have no idea, so he'd finally open it up to anybody to answer, and reward the answer with a direct line of questioning that would lead us to collectively lecture ourselves on bullet trauma to the flank, simultaneously easy enough for some med students to answer questions, with a few difficult statistics questions for the residents thrown in to disseminate the most modern protocols currently being developed in medicine.

In the meantime, he would talk us into coming up with the solution to a problem ourselves, instead of having it taught to us. If you can get over the embarassment of not knowing the answer to a question, it inspires confidence that you can, deep down, figure these things out even if you forgot the specific protocols. After all, coming up with your own protocols and decisions is the basis for every major profession out there, not only for doctors and lawyers for whom Socratic method is taught.

Anyway, it's a welcome change from 2 years of classroom education.