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Why is it so hard to pay attention?  What is your attention span?  What was your last thought, and what is the one before that?

If there is a crying need in the educational system, lies in the training of people to pay attention.  Attention lies under the authority of willpower.  It is associated with concentration, and it is a crucial element of perception.

There is no more important and fundamental lesson in the pre-clinical years than the exercise of attention itself.  It is a personal instrument for knowledge and understanding.  Therefore, it is the most coveted prize for the control of human thought.  Capture one’s attention, and it’s like capturing a unit’s flag in the battle.  They exist no more.

The capacity for attention and scrutiny involves the aggressive suspension of irrelevant thoughts which intrude into one’s awareness.  A clear and relevant thought is an element of perception – an irrelevant thought, a distraction.

Advertisers prey on this weakness, for they make a profit from this weakness, the lack of stubbornness that keeps one’s focus on the actions of mind which the person themselves wills.  Wanna see LOLCATS?  and now it’s off to the funny cats, and etc., etc.  The Internet is a training ground for the fragility of the mind’s attention, and the advertisers know it.

The IT and business world knows it.  Instant Messaging in the clinic, Stat Emails!  Let me just interrupt to tell you….. Interruption is distraction, and distraction is rude.  One should allow another at least a few seconds to compose one’s thoughts, to set them aside and attend to the new matter at hand.  But our minds are now an ER of problems.  Nothing gets done, but urgently.

School, nowadays – and this involves medical schools – offers a bundle of content, all of which is dependent on its capacity for later testing.  There first is an assertion; next is a question, to test whether that assertion can be recalled.  If it cannot, the assertion is not properly embedded in one’s memory, and the student fails.

The current educational system presumes that the nature of existence in one aspect – renal pathology, pharmacology – consists of a discrete and countable number of associations which must be learned in orthodox manner to achieve knowledge.

There is great value to those associations.  But they do not engender expertise in renal pathology or pharmacology.  They map a coastline.

In mathematics, the coastline paradox is merely the observation that the simple question – how long is the coastline of South Carolina, for instance – is a highly complex problem which may be unsolvable.  When one estimates it, using a ruler of ten-mile length, the answer is clear and rapid; that of a one-mile length, more time-intensive but more accurate.  The smaller the ruler one uses, the more “correct” the answer is, of course.  And the estimates all converge upon a single number, which becomes more and more precise as the measurement ruler gets smaller.

But there is no limit, not in pure mathematics.  One can imagine using an inch-long ruler; factors such as tides and waves would become predominant at such time, but I’m not talking about that.   In practical reality, a millimeter ruler – that the size of a grain of sand – may suffice as the endpoint.  But in theory, there is no endpoint.

The myth in many systems is that this collection of associations comprises a sturdy reality.  The truth should be told, that it only acts as a rickety set of associations which are often generally true.

The measurement system for medicine is predicated on the myth that these coarse and peculiar assertions have sufficient grounds in reality, that they may substitute for clinical judgment in some certain area.

Assuming that the teachers teach something well-founded in reality, and they do so honestly and intelligently, there still may be grounds for doubt.  Shortly before I trained, the myth was that beta-blockers were injurious after a heart attack, as they can depress the heart’s response to increased demand.  Digoxin, an inotrope, should be used.  The theory was brilliant; the facts showed the opposite.

The dimension of ways that patients may present their illnesses is practically infinite.  The mathematician would likely disagree, and insist upon “finite but large.”  Infinite’s a pretty good approximation.  Diseases tend to cluster and present a certain way, but that way offers no real boundary – it has no edge.  Diseases may present in an “atypical” way, and one’s hornbook or Washington Manual may be unhelpful.

My neighborhood of practice has a decent-sized population of people of Mexican ancestry.  I have never seen it written up, but I find that Mexicans, and people of Mexican ancestry, run a higher average, but normal, TSH as compared to the US population.  Their T3 and T4 are normal.  Since TSH exists only to regulate the T4 levels to normal, a “High TSH” is spurious.  But it is a measurement factor in Quality Assurance.  Therefore, I find that many of my patients are on a tiny dose of T4, prescribed for “hypothyroidism,” that represents no pathology of the thyroid gland nor the adenohypophysis.  It is a “disease” that is “treated,” in the sense that an intervention is supplied, an intervention which is small and benign.  Nevertheless, it is spurious.  None of these patients have had any symptoms of hypothyroidism; nor have the providers practiced enough medicine to recognize clinical hypothyroidism.  I have.

The clinician’s hand is an INCREDIBLE thermometer, when sufficiently trained.  I find it good to within decimal-points of degrees.  If you have not touched a 95° F patient, you do not know how chilly they feel.  One’s perception is of 75°F, not 95°F.  They are cold, stiff and slow.  But who has ever seen a patient sick like this?  Certainly not the people rushed through the classroom, who learn that “hypothyroidism is when the TSH is above an indicated level.”  It most certainly is not.  But teaching about real hypothyroidism involves the threat of the outbreak of genuine medicine.  That must be suppressed.

Does your patient have cold intolerance?  Are they slow, is their hair thick?  Do they have nonpitting lower edema (although this is rare?)  Do they ever have symptoms of heat intolerance, tachycardia, or other symptoms reaching towards Hashimotos?

We are taught that these are check-box questions.  Actually paying attention to the PATIENT, one can determine whether they have clinical euthyroidism or not.  And that is the hardest part.  Clinical euthyroidism does not merit treatment.  But how would the busy or uninformed practitioner know?  Paying attention is the only way, and the practitioner who has made it through the educational system by then is good at not paying attention.

More discussion will come of this.  However, the key and critical lesson in every classroom in college is – learn the particular tricks to getting an ‘A’ in this class, and then promptly forget any content you might have accidentally learned from the class.  Retain just enough to look educated at cocktail parties.  “Shakespeare, of course.  Ben Johnson?  Francis Bacon?  Hamlet and MacBeth and Starry Night (sh*t, did I just say Starry Night?)  As You Like it, Twelfth Night.  Blu-blah-blah.”

 

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