“The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn.”
Learning is a complex process. I wish it were as simple as picking up a book reading it up, committing it to memory and regurgitating the stuff as and when needed. I mean, that’s what most of us were taught to do in school, isn’t it? And I must have done that well, going by my school grades.
It’s when one needs to use the knowledge that one realises that merely regurgitating the stuff doesn’t help. At some level that knowledge has to enable decision and action. And hopefully evaluation and reflection.
5 years ago when it was time for my daughter to leave for university, we decided to do a campus trip to survey three institutions she had to choose between. The first stop was the Hyderabad campus of BITS Pilani. A wonderful Biology Professor took us around the 240 acre campus ensuring that we saw everything. And she was game to take any questions. In the course of our conversation, we discussed the no attendance requirement that was special of BITS. She smiles and said that this was something that caused a great deal of difficulty to the first years. “ you know, the majority come here from having spent their class XI& XII cooped up for 12 hrs a day in residential coaching institutions. The combination of a free campus, no minimum attendance requirement and a good internet connection across the campus and the students , especially the boys spend their nights competing in computer games across the inter hostel LAN network. Then they wake up late, miss classes and there’s tragedy at the end of the year!” She then said” These coaching classes only teach them tricks to solve entrance exam problems rather than actual concept, so we are faced with needing to coax them to come to class plus unlearn their previous methods and start developing active learning skills”.
Unlearn- yes, I liked that word. In fact I remembered using it a decade prior when I was writing my reflective diary as part of my Specialist Registrar Training program.
In late 1996, appearing for my first interview for the post of an SHO in Paediatrics ( equivalent to first year MD Postgraduate in India) , I wrote my first CV. I saw the headings my hubby had used to draft his ( and he got the job, so it must be ok!) and used the same template. One of the headings was Procedures that I had performed. Since I had already completed Paediatric Postgraduate training in India , I compiled a LONG list of procedures I had doubtless performed . Apart from venous access, both peripheral and umbilical ( newborn) , venous cut- down, there were a good number of biopsies- lung , liver, bone marrow, kidney, then pericardial aspiration, Intercostal tube insertion, and more. While I could intubate a newborn on the resuscitaire, my knowledge of elective planned intubation was scant, ventilation was nil and central venous access nonexistent. The two very English consultants who were interviewing literally had their eyes popping out of their heads when they read of my prowess! I did get the job. It was a District General Hospital with an almost tertiary level neonatal unit and General Paediatrics sans many paediatric specialties. And from my first day onwards, I started developing significant insight into what I knew , what my limitations were etc. Over the many years and the very many experiences, I realised the importance of stratifying care to primary, secondary and tertiary and training to appropriate levels. Therefore, a General Paediatrician really didn’t need to develop procedural skills beyond venous access, excellent resuscitation skills and neonatal ventilation skills . The numerous biopsies I had learnt to do need not be learnt at that level, but at the tertiary level. I realised that there was much more to know than just doing a bone marrow or liver biopsy or renal biospy- knowing when they were required , and referring them to experts for doing them made more sense because they could understand the report and how to act on it the best. But every Paediatric trainee needs to be able to interpret a clinical scenario enough to keep the patient safe and whether they can continue to manage them or they would benefit from being referred on. The onus was first of all to be a Safe Doctor , rather than a multitasker.
There was a lot I had to unlearn to be able to learn and progress. And modifying that CV especially that Procedure list was one of the first things I did!
I had to pick up so many new concepts- of audit cycles, recording followup , watch and learn patient counseling , how to put across a clinical case scenario in a meaningful referral and hold a dialogue with tertiary centres and from tertiary centres too. The importance of planned professional critical care retrieval and transport can make to survival outcomes in critically ill children. Like most Paediatricians I too romanticised over becoming a Neonatologist / Paediatric Intensivist. One experience with a 14 hour stabilisation of a neonate with brittle oxygenation due to Persistent Pulmonary Hypertension( a favourite terminal diagnosis in Tamil movies often made by looking at a CXR or feeling the pulse) , and a few more very skittish situations told me that I did not fancy sacrificing sleepless nights into my 50’s and 60’s, so I sought other specialties.
The other major insight was how much one could learn on the job. My mentor in Paediatric Rheumatology told me on my very first day that there was plenty of opportunity to learn in the department but my learning would be proportionate to how much effort I put into it. And that was so true. Infact , I could have learned much much more than I did! We often had seated ward rounds in a closed room with coffee where patients were discussed at length – possibilities and plans threshed threadbare, so that the actual physical round was literally for bedside decisions and communicating to the families. These meetings were steep learning curves for me as well as the multidisciplinary meetings in every tertiary specialty I worked in. There was one patient with Systemic Onset JIA who was so difficult to treat we considered referring her for a bone marrow transplant. The referral itself had a set structure and finally came up to a 45 page document and at the end of preparing it, the amount I had learnt was phenomenal.
There was no theory assessment, no viva but the annual SpR assessment from the deanery looking at our own account of our progress made and our educational supervisor’s assessment was quite a gruelling experience!
It showed me truly how designing training needs to fit the future professional role is really important. If such planning had existed in India much earlier, tertiary Paediatric specialties would have come into existence much earlier too. For this however , previous set concepts about the robustness and greatness of our training do need to be unlearned first. Awareness of the importance of recognising ones own limitations and seeking help and cross consults with appropriate specialists is truly important to the end user – the patient! And finally , to realise that the end of training only signifies the beginning of experiential learning – another steep learning curve. My husband recounts how the day he passed his MS Orthopedics exam, the examiner shook his hand and said – “Congratulations, your real learning starts now! “
As I write this, it’s now the time for my son to move on to college and we hope he gets into a program that will build and enrich his critical thinking skills . He will of course have to go through considerable unlearning in the process!
The mind is slow to unlearn what it learnt early.
Seneca the Elder