Medical school kills curiosity

vivianimbriotis | March 8, 2020, 1:46 p.m.

I have always been intensely curious. I want to know how things work, and it irritates me when a question doesn’t have an answer. This is part of the reason I like medicine - the process of diagnosis is the process of finding a satisfying (and hopefully helpful) answer to a question. This is what drives me to learn mathematics and music theory and philosophy and, in general, to waste my time.

I find myself suspicious that some aspect of my medical degree has made me less curious, somehow, and so do many other medical students I’ve spoken to. I’m not the only one to think this. But why might this be the case? My lectures are often delivered by highly passionate scientists that enjoy their work, the kind of people that inspire me to more intensely interrogate the world. I am frequently studying fascinating subject matter. What gives?

Let’s break the claim down into components. First of all, do medical students become less curious over the course of their degree? Secondly, do they become less curious over the course of their degree, compared to other people of the same age, over the same course of time? Thirdly, is there a causal mechanism from the experience of medical education to the lack of curiosity?

PART ONE: CORRELATION

What I really want to find is either (a) a longitudinal study that follows medical students and uses consistent questionnaires to gauge their levels of trait and state curiosity as they progress through training, with blinding as to the student’s year level, or (b) a cohort study that compares first-year medical students’ measured curiosity to that of final-year medical students, again with relevant blinding. To the best of my database-searching abilities, these studies do not exist.

A McGill study by Sternszus et. al. measured Trait and State curiosity of medical students enrolled in a four-year program. There was no comparator group. A standardized metric, the Melbourne Curiosity Inventory, was used, which divides curiosity into “State” curiosity, attributable to the external environment, and “trait” or inherent curiosity. It found that state curiosity was lower than trait curiosity overall, which they took to indicate that there was a lack of support for the curiosity of medical students. I am unsure if it is appropriate to draw this conclusion from a difference in absolute value between the two different components of the Melbourne Curiosity Inventory – for all I know, measured state curiosity might almost always be higher than measured trait curiosity – or might always have been measured higher with this groups particular set-up – and without a control group to compare against it seems impossible to know. Also, this group aggregated the data of all four year-levels of students together, so I can’t parse out whether this data illuminates any kind of trend.

The most comprehensive article I can find adjacent to this subject is “Curiosity and medical education” from Dyche and Epstein 2011 (no, not that Epstein). It focuses on the ways that medical education “may” inhibit curiosity and proposes strategies to nurture curiosity in medical students, but doesn’t tackle whether or not there’s actually a discrepancy in inquisitiveness.

PART TWO: CAUSATION

Even if a medical degree is correlated with a fall in curiosity, is there a causal mechanism from the experience of medical education to the lack of curiosity? There exist non-causal explanations - for example, a selection effect.

Say everyone’s degree of intellectual curiosity fluctuates over time. Medicine might select for those whose curiosity is high for a certain critical period - either because medicine appeals to people who are particularly curious at a time when deciding on their university course, or because that curiosity helps people who would otherwise not attain the requirements to study the course to do so. If this were true, then medicine would select for people whose peak curiosity was before beginning medicine, and select against people whose curiosity was at a nadir at that time. Then, as those medical students progress, they fall back to their mean levels of curiosity, and would have done regardless of medicine itself.

(in aggregate, neither of these people are really that much more or less curious than the other, but the medical student’s curiosity is high in School, causing them to study medicine, and then falling during their actual studying years).

Medical students are very anxious and exhibit a lot of imposter syndrome. This could be due to yet another selection effect - people who are very “type-A”, very focused on academic success, do very well in tests for entrance into medicine, but are comparatively less curious than other cohorts. Alternatively, maybe all formal education reduces curiosity (this seems like a stretch) or maybe aging naturally reduces curiosity (more believable).

Some clinicians certainly seem to believe that curiosity is hampered by a medical education.

“There’s a dynamic tension here. People pursue medicine because they are curious about the human experience and scientific discovery, but early in training they are taught to place things is categories and to peruse certainty.” – Ronald Epstein, MD

What I really want to find is a study that compares medical students’ measured change in curiosity from their first to Nth year against other tertiary students measured change in curiosity from first to Nth year and see if medical students fare worse. Again, this study doesn’t seem to exist (yet, maybe I’ll conduct it).

PART THREE: ATTRIBUTION

All that aside, if medical students really do become less curious, and that really is attributable to medical education, where does that leave us?

This is where Dyche and Epstein really shine. They supply 4 components of medical education which they think may serve to inhibit curiosity:

1.   Haste

2.   Suppression of negative emotions

3.   Overconfidence

4.   Passive Learning

Haste

There’s a saying in medicine that really horrified one of my friends. It’s “See one, do one, teach one.” It means you should only have to see a procedure done once before attempting it and should only need to attempt a procedure before being able to teach it to someone else.

This is dumb.

This is obviously dumb.

If medical procedures are easy enough that you only need to see them once to be able to do them, then doctors should be paid much less than, say, builders – you need to see multiple houses built before you attempt one yourself. This saying is meant to apply to simple procedures like venipuncture and cannulation, but I think it belies a deeper culture in medicine, that learning should happen quickly.

Good learning doesn’t happen quickly, and if you try to force people to learn things quickly, they burn out, don’t have the spare energy to remain curious about things, and just cram and rote-learn the content that they are required to know. There’s less space of the fruits of inquisitiveness – making higher-level connections between concepts, abstracting over details, and building schemas and frameworks to organize information.

Suppression of negative emotions

Dyche and Epstein say that medicine encourages the suppression of negative emotions like disgust and anxiety, and that this results in worse patient outcomes and also results in burnout. They don’t explain, however, how this relates to curiosity.

Overconfidence

 Dyche and Epstein say that medical students are socialised to project a veneer of unflappable confidence, and that this prevents them from acknowledging uncertainty, which prevents them trying to fill the holes in their knowledge by asking questions.

Passive Learning

I can’t say this one better than Dyche and Epstein did, so I’m not going to try. “Curiosity requires to opportunity to challenge convention and assumptions. Efforts to support best practices in medicine and to contain medical error through emphasis on protocol can inadvertently suppress learners’ opportunities to question medical knowledge. Teaching is typically conducted in hierarchically organized settings, such as lecture halls…Because expressing curiosity in these settings can involve risking criticism or humiliation, the learner often chooses to play a safer, passive role.”

Ultimately, curiosity is about asking questions, and to be an inquisitive learner you must be able to ask dumb questions. I have rarely felt safe to ask dumb questions in the environments in which medicine is taught and have heard other students around me express similar sentiments.

PART FOUR: IMPACT

There’s a tension in the medical field right now. On one hand, doctors experience extreme levels of burnout and fatigue. Doctors, to a certain degree, are workers, and are exposed to pretty significantly traumatic situations for the good of others. Asking doctors to do more runs counter to the ideal of putting on your own oxygen mask first. Doctors are burnt out and anxious and depressed and committing high rates of suicide.

Conversely, some doctors are better at medicine than other doctors. I expect that as the scope and complexity of medical knowledge expands and accelerates, the ceiling on how effective a physician can be will also increase, so I’d expect that bell curve to flatten as the mean rises – if doctors can do more, then how good your doctor is at medicine matters more. The increasing size of the medical corpus of knowledge therefore implicitly imposes a moral imperative on doctors to do more. And as Dyche and Epstein say, “Doctors are more than technicians: they must have adaptive expertise, the ability to manage the unexpected…The importance of seeing the world in multiple ways cannot be understated…it is the primary substrate of clinical reasoning, healing relationships and patient-centered care.”

Curiosity is important because (a) I think it is likely to be protective against burnout and (b) because it is a trait that selects for better doctors, and as a society, if we care about health outcomes (whatever those are) we ought to want both of these things.

PART FIVE: MOVING FORWARD

Firstly, there’s really no serious research here, and I would like for there to be. Dyche and Epstein have more words for educators on how to foster curiosity, but I’m not an educator, I’m a medical student. So how should students that value curiosity in medical practice, but believe that medical education suppresses curiosity, move forward?

Maybe the answer is to just weather the storm and rekindle our intellectualism as medical professionals, but I don’t think so. I think the answer might be “be defiantly inquisitive”. But don’t ask me, I took an honors year.