I have had a roundabout route to becoming a physician; having first done an undergraduate degree in biochemistry, I then switched departments and did my Master's in Physics before deciding to apply to medical school. During my Master's I was exploring a very niche area of science: Experimental Cellular Biophysics. A basic synopsis of my research is that I spent hours in a dark room poking fluorescent cells trying to figure out how they responded to being poked.
The motivation, you see, was that Biologists and Physicists imagined a cell in very different ways. When trying to explain phenomena, the physicists tended to imagine the cell as a ball filled with liquid and modeled all their equations based off this highly simplified version of a cell to try and explain how it would respond to being poked. The biologists on the other hand, understood the complexity and interconnectedness of the various cellular components, but were unable to apply any of the physics necessary to describe the mechanical processes that were occurring. The beauty of our lab was that we had students with varied backgrounds; not just biologists and physicists, but also engineers and biochemists. We were in a unique position to tackle this murky area of science.
My work, published in the Journal of Cell Science in 2012 (linked here for those interested), highlights some of the particular challenges of attempting to understand complex systems. It was known in the literature that cells were capable of responding to force, but it was sort of a black box phenomenon; nobody really understood all the components involved or how it worked in the short term even if the long term results were predictable. We designed several experiments to explore this short term response of cells to externally applied forces, and were able to demonstrate the dependence of a response on multiple aspects of the cytoskeleton, as well as generating a 'map' of how strain was distributed throughout the cell. I remember looking at the results of my strain experiment and being completely baffled: they were TOTALLY DIFFERENT than what we had anticipated. With my supervisor's help, we discovered that, while individual points had apparently random values for strain, there was a predictable increase by 50% in the variance in strain when a force was applied over the whole cell. To translate, that means that there was a whole lot more motion going on, and, while unpredictable on a local scale, the large scale changes were more predictable.
The inevitable next question was then: "Why?" We didn't have a great answer, but like any good scientist, we came up with a hypothesis that was equally grounded in my experience in complex biochemical interactions as it was in the simple mechanics of a physical system. I still can't tell you if our hypothesis was right, but these experiments certainly did help to understand many of the components involved in a cell's response to forces. Eventually, they might even be used in medicine to tackle building organs out of stem cells or targeting cancer cells by their different mechanical properties.
I was reminded of my work today while reading through Geoff Norman's article Chaos, complexity and complicatedness: lessons from rocket science. Having read through several of the articles to which it makes reference (especially It's NOT Rocket Science by Glenn Regehr), I found myself agreeing with Norman on several of his points. The debate, to summarize, is whether we would be better off abandoning attempts at understanding interventions in medical education through reductionist scientific methods (seeking simplicity) to embrace a theory ground in complexity and chaos theory to describe the multi-dimensional systems in which medical education is produced and implemented. Arguments in favour of this point out that much of the literature is simply incomparable to each other: what works in its own microcosm does not work and is not applicable or widely generalizable to other medical schools or systems. Thus, we would do better to not even try to make a generalization. I however, find myself siding far more with Norman in his cautions that this would be a dangerous undertaking.
I particularly understand the point he is trying to make in cautioning the use of chaos and complexity theories to describe the state of medical education as those using the terminologies do not seem to truly appreciate the physics or basic tenets on which they are grounded. He also argues that there have been several well designed 'simplistic' experimental interventions in medical education that we risk disregarding by embracing chaos. He summarizes: "the issue at hand is whether this lack of predictability at the individual level represents an ultimate failure of classical scientific methods, or simply a psychosocial 'uncertainty principle' reflecting an ultimate limit on knowability."
I feel like many parallels can be drawn between work in interdiscplinary science, such as my Master's work, and in fields such as medical education. With my lab, it would not have been possible to come up with a generalized theory to explain our particular results without the knowledge base of both physics and biochemistry. What's more, we were also operating on a complex system for which we could not see all the moving parts, but we COULD see the overall result on a whole, both long term and short term. In medical education, it seems to me there is much the same divide. Much of the understanding of complex educational principles lies with the cognitive scientists, psychologists, and social science experts; however, it is the physicians with backgrounds in biology, physics, and the reductionist scientific method who are attempting to implement the best education curriculum possible, and they find themselves at an impasse. The physicists who were attempting to model a cell as a simple ball of fluid were wrong to ignore the complexity of the cell, but they were not wrong to continue to use linear-model physics to try and understand the system. Similarly, I think that in medical education, we should absolutely continue to apply an approach that is grounded in linear-model reductionist principles while acknowledging the complexity of the system.
Perhaps it isn't so much about asking "Does this work?" but more about asking "Why?" and "How?" And, even if we can't demonstrate an exact predictable response on the individual level, that doesn't mean that an understanding could not be found on a larger scale that could then be generalized and applied to other situations. The answer to what works in medical education lies as much in the details and the failures as much as successes. We should be asking our colleagues that are experts in education science for their input and collaborating by using qualitative methods in conjunction with quantitative to develop the best possible medical education interventions. I'm a firm believer in collaboration with people of varied backgrounds and creating an interdisciplinary team to find creative solutions to the problem; it's time for medical education to "think outside the box".
~LG
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