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What’s in a doctor’s brain, and what’s online

No one, not even a doctor, can remember everything. Medical educators are studying what information a doctor should have at her fingertips and what’s better looked up online.

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In the typical adult human, there are 206 bones, at least 700 named muscles, 78 organs, 12 pairs of cranial nerves, and 32 pairs of spinal nerves, and a formidable array of named veins and arteries, all of which, during medical training, a budding doctor will be asked to commit to memory. That, of course, is only the beginning. There are an untold number of procedures to memorize, as well as a host of diseases‒currently more than 30,000‒to cram into the cerebral cortex, and when the training process is complete, assuming it is ever really done, physicians are expected throughout their careers to dig into their brains’ hard drives and retrieve relevant information quickly, effortlessly, and flawlessly.

But in the modern technological era, when tablets and smartphones are as much a part of a doctor’s regalia as a white coat and a stethoscope‒Yale students receive iPads when they enter medical school‒does it still make sense to engage in all that memory work? Neurobiologist Michael Schwartz, Ph.D., associate dean for curriculum, said that’s a question worth exploring. With the explosion of knowledge and the ease with which it can be accessed by technology, he said, we need to be more thoughtful about which facts need to be in the memory for immediate application. ”Memorization takes up far too much cognitive bandwidth when we should be focusing more on the application of knowledge. Technology now gives us the opportunity to access all that information instantaneously, and this is changing the way we train doctors and practice medicine.”

Internist Auguste H. Fortin VI, M.D., M.P.H., believes that it’s mostly a change for the better. ”Most of medical education has revolved around filling up the empty vessel with facts, but with scientific knowledge growing explosively, no one can possibly keep it all in mind,” said Fortin, who teaches communication skills and always has his iPhone handy in the exam room.

While there had been fears that computers of any variety would be seen by patients as intrusive, those worries haven’t played out. ”I’ll tell patients when I’m looking something up that I’m almost positive about the condition, but I just want to double-check and make sure my recollection is correct,” Fortin explained. ”And I show them what I’m doing so they know I’m not texting or checking my shopping list. The iDevice has become a partner, a way to ensure quality control and improve patient care.”

The fact that Fortin is less reliant on memory is a big plus since he freely admits that his memory is less than photographic. ”I remember sometimes having to invent a pretense to leave an examination room so I could go back into the office to look something up in a book,” he explained. ”There was a bit of shame in this‒I didn’t want a patient to know that I didn’t have it all in my head.”

That shame is gone, but while Fortin may not have the entirety of Harrison’s Principles of Internal Medicine at his cognitive fingertips, he has all of his specialty’s typical procedures, to say nothing of an impressive array of facts, at his disposal. This doesn’t include the proper dose of every medication imaginable‒these are readily available online‒but Fortin and his fellow internists know by heart the proper flow of a patient encounter and the skills needed to draw out a patient to effect a differential diagnosis. ”You memorize the more common situations, like if you see someone with chest pains who has these particular qualities, you might be looking at diagnosis A, B, C, or D,” he said. ”You vaguely recall that there could also be E or F, but you’d have to look up the specifics.”

The emphasis on methodology rather than memorization is where medical training is heading. ”We’re actively trying to determine the base level of knowledge a physician absolutely requires to do the job, especially in an emergency when you simply don’t have time to look things up,” said Schwartz. ”Figuring this out is one of the primary challenges of modern medical education.”

But if the jury is still out on precisely what a doctor needs to memorize, the proper habits of mind are clear in the iAge‒or any age. ”One of our central tasks as teachers is to instill in students the value of looking things up and, of course, teaching them where to obtain the highest and most reputable quality information out there. This is where medical research librarians are worth their weight in gold,” said Fortin. ”You have to be confident in what you know, as well as confident that you can find out what you don’t know or can’t quite remember. But above all else, you can’t forget that the patient‒not the iPhone, tablet, or any other iTool‒is your focus. These devices are just another way to make sure that you have things right.”