I’ve been a “self-taught” individual for my entire life.
I grew up in the late ’90s and 2000s, and the internet grew up with me. Its utility matured as a medium at the same time as I was maturing as a person. I discovered that for the curious reader, it could provide information on nearly any subject, from the mainstream to the niche—material that would otherwise be nearly inaccessible. From encyclopedias to how-tos, and always at least one listserv or forum populated by world experts, it had it all. It was also remarkably egalitarian and democratic, allowing access and a voice to anyone, regardless of their age or background. From this fount, I taught myself to build websites (and did it as a freelancer), pick locks (eventually becoming a licensed locksmith), and more.
Then I came into the world of medicine, first as an EMT and then as a PA. Meanwhile, the concept of web-based medical education (popularized as “FOAMed”) has boomed, creating an embarrassment of riches for those like myself predisposed to reading, listening, and learning on their own.
Yet along with this vast potential comes some pitfalls. Here are a few tips for the medical professional trying to navigate the modern self-learning environment.
1. You can teach yourself a lot…
The top avenues for medical self-education are probably these:
- Original “FOAMed.” This is a medium practically invented by the internet, and at its core consists of educational blogs and podcasts. (We list some here.) It’s mostly a smorgasbord of individual providers expressing their passion for education in a new, far-reaching way, and as idiosyncratic as it may seem, this is where some of the best stuff lives.
- Formalized “FOAMed.” The slightly more evolved form of grassroots FOAMiness. Often it is the product of residency and fellowship programs, or hospital departments with a penchant for progressive education, putting out well-done websites or podcasts drawn from live lectures. (Great examples are the University of Maryland’s Critical Care Project or the Louisville Lectures.) Some costs money, but is still worthwhile. Even traditional blogs have started to formalize their work with editorial panels and a peer review process.
Through these resources, one can learn a tremendous amount, particularly in certain fields, the busiest of which has been emergency medicine.
2. … but you can’t teach yourself everything.
Despite these troves of free information, it is essential to recognize that you can’t pull yourself up entirely by your bootstraps.
You cannot learn it all on your own. You can not.
Traditional medical training follows the apprenticeship model: the learner is attached to masters, and gradually—through instruction, modeling, and often, through abuse—learns to mimic and execute the skills of the trade. This is about as far from self-learning as you can imagine. And yet, there’s a reason it became the norm in our field.
The number of skills needed for a medical practitioner, from large to small, are innumerable. Some can be learned from a book or blog. Some can’t. And crucially, many will not be obviously missed if a senior isn’t there to point it out.
A good autodidact can study the world’s literature on focused subjects and become brilliantly knowledgable on, say, ECG interpretation. He can learn everything that’s known about a disease process or the data on a new drug. She can memorize whole textbooks on pathophysiology or diagnostics.
However, crucial skills will be left missing with this approach, such as the following:
- Frameworks. A thousand facts are not useful without a way of thinking about and applying them. Since mental models and “approaches” to certain problems are not facts, but a matter of style, they are rarely found in books; they are taught by our fellows. There are usually infinitely many versions of these, but you need to pick up a few that work for you, and they probably need to be taught person-to-person. “This is the way I was taught it,” you will often say, recognizing that it isn’t the only way, but that having been taught no way would render you impotent in your daily practice.
- Professionalism and behavior. It’s one thing to know how to practice medicine, but how do you do it? How do you look, how do you present yourself, how do you treat your colleagues and your patients? How do you guide a patient’s history, call a consult, teach a student, or defuse hostile situations? Learning to become the provider, not just act like one, requires mentors and a process of immersion.
- Psychomotor skills. You can read about technical procedures. You can even watch them demonstrated in images or videos. You cannot learn them without hands-on instruction.
What this all means is that some formal, personal training is irreplaceable. Consider my own field: physician assistants typically come from school trained as generalists, which means practicing in a specialty field like critical care requires additional training and experience. This can be acquired on the job, and augmented by self-education. However, the sort of structured, comprehensive didactic environment offered by a dedicated postgraduate residency/fellowship program offers another level of preparation. While not essential, it does build a unique degree of knowledge and experience that cannot be replaced by any amount of reading.
3. You don’t need to spend money…
Many of the best resources for self-education are free, which is one of the great triumphs of our era. Decades ago, the library was the only equivalent, but being limited to textbooks and journals, it left much to be desired. Now, more timely, focused, and personal learning is available all over the web.
4. … but you should spend some.
Recognizing the limitations of FOAM and its ilk is just as important as embracing the strengths.
While brilliant educators and thought leaders have put countless hours into developing free educational content, some things are just not going to be free. Sometimes they are too labor-intensive to create without compensation. Sometimes they require financial outlays for personnel or physical assets which need to be recovered. And sometimes, you need to physically attend a physical session to learn things, and that costs money.
Accept that you will get value from attending an ultrasound seminar, an airway course, or a good conference that you will never replicate from your living room. The material will be different. In some ways, it will be less efficient and less perfect than you could find elsewhere. But some elements will be uniquely valuable, and trying to develop your craft without this will leave you lacking.
5. Beware of the gaps
One of the benefits of self-education is that you can focus on what interests you the most. This is also its weakness.
Formal training curricula are built for comprehensiveness; a list of objectives is created and you are taught them until they are learned. If instead, you are able to build your own curriculum, what will you focus on? Probably the cool bits that pique your interest. The rest, not so much.
This is a problem. An even bigger problem is the unrecognized gaps. By a haphazard learning approach, you may develop sufficiently deep expertise in certain areas that you convince others—and yourself—that you are an expert. But because it lacked a systematic approach, you may be missing remarkably basic pieces that a traditional learner would have been taught on day one. Danger lies here.
Minding the gaps can be easier said than done. Once past formal training, opportunities to be externally evaluated are few, and self-evaluation is far too likely to glide over weaknesses.
Actively seek opportunities to assess your strengths and weaknesses, particularly the latter. Explore training in areas you don’t consider your bread and butter. When collaborating with colleagues and supervisors, specifically ask if they have suggestions, ideas, or things they’d do differently—otherwise they may let it slide, and you’ll never know the things you could improve.
Consider giving out surveys to your coworkers, preferably anonymous ones, allowing them to evaluate you without fear of personal friction. This is common in training but less so after graduation.
Look for assessments like the SCCM Multidisciplinary Critical Care Knowledge Assessment Program, a mock board exam taken online (it costs a bit of money). Although it means nothing, it gives you feedback on your knowledge base in different categories and even on specific topics, allowing focused self-remediation on your own time.
7. Be open to theory; be skeptical about application
Others may advise you to apply a critical eye when reading about a new study or a narrative review. This is good advice, but probably not needed. Most providers trained in the modern era receive an adequate education in evidence-based medicine and methodology.
When it comes to reading or hearing about new ideas, be liberal. If espoused by reasonable, intelligent people, few concepts are not worthy of consideration. Of course, they must be analyzed and accepted or discarded according to their merit, but don’t turn them away at the door.
On the other hand, new practice techniques need to be entertained much more judiciously. The FOAM world is full of descriptions of interesting, novel, and progressive approaches to managing certain disease processes or performing certain procedures. Many may sound like a salutary addition to your own practice.
But the bridge from blog post to the bedside should be a fairly long one if you are not very experienced indeed. If you were taught to do things a certain way, it may not be the best way, but it is at least a reasonable way. It was the accepted practice by the people who trained you, all of them probably of sound mind and long years. It will work, more or less, and not kill anyone, and its caveats and pitfalls were taught to you and baked into the technique.
The new approach you hear about at a conference does not come with these. The fact that it worked for the expert does not entail the same success for you; it may require a context you lack, from practice environment to personal fund of knowledge. If things go wrong, you will have nobody to turn to.
Accept new methods with a cautious, reasoned approach. Consider all the angles, including how it might go wrong and what you’d do. Ask others in your shop what they think, from your colleagues to your superiors. Check the literature in its entirety, not just the vocal or charismatic source you started with. Only when you’ve truly considered all the angles should you consider implementing it on your next patient.
8. Seek experiences to transition theory into practice
The flip side of the above is that if knowledge never changes your practice, it may as well never have been learned. You do want to change, evolve, and broaden your practice based upon your learning; having left the formal training setting, you’ll just need to seek out the chances to do so on your own.
The upside is that you’ll be able to seek out precisely the experiences you desire. The downside is that you’ll need to do so actively, because they won’t be presented to you. One can easily practice medicine for 30 years and learn very little along the way, because you’re practicing the same medicine day after day.
An example: airway management is a challenging skill, with many steps to mastery. Regardless of theoretical understanding, its psychomotor learning curve is long, and the first portion is steep: getting from zero experience to the experience that allows you to safely manage an airway (even with supervision) can be difficult to do, and almost impossible outside of a training environment. If you’ve never intubated, it’s hard to look at a crashing ICU patient and say, “Hey, how about I try this one?” Ideally, your first several dozen will be in the OR, in a controlled environment, closely supervised, with stable patients. So seek that out: ask the right people from the anesthesia department and find out if there’s an opportunity to spend time with them. It will never happen on its own, so if you want to add those skills to your practice, you will need to carve out the opportunity to learn them.
9. Recognize that nobody knows what you know
The benefit of formal education is that it usually comes with a label.
Graduate from medical school, PA school, or nursing school, pass your exams, and you get stamped with a license or certificate that tells the world you have a baseline level of knowledge. A stranger won’t know you, but knowing your title, they’ll be able to assume you have certain basic abilities.
Very basic ones. This can be further evolved: the physician who finishes a residency in internal medicine, and then a fellowship in critical care, is “stamped” with a different, larger set of skills. But the less formal training you undergo, the less the world can assume about you.
You may know very much indeed. But nobody knows that you know it. So you’ll need to navigate the professional environment recognizing that the people you meet, unless you have a relationship with them, will probably default to the lowest common denominator. For someone like a PA or an RN, this means a fresh graduate, and that means people will assume you don’t know much. You may have experience that is both deep and broad, but nobody will recognize that at first.
You’ll need to convey the strength of your perspective with your carriage, your words, and the soundness of your assessment and approach. Don’t feel belittled if they speak down to you; base your position on good science and good practice, and they’ll gradually realize its merit. Finally, accept that this is difficult for them too: it’s much easier to deal with colleagues who have an imprimatur of competence than it is to deal with “wildcards” like APPs who range widely in experience and training.
10. Don’t stop
When you’re young, hungry, and ambitious, self-education is easy. Medicine is full of things to know, and all of it seems fascinating.
The process of winnowing usually starts early. The learner who was fascinated by every topic in school may find within a year of graduation that he couldn’t care less about topics outside his purview, like rashes and joint pain. Without effort, this process can continue for years, until you become the ornery old guy who hasn’t learned or changed in decades and isn’t interested in starting now.
Keep it up. This will require some agility, because the things that once interested you may eventually lose appeal. New ones will take their place. The methods will also evolve: you may have once listened to podcasts on your long commute, but now stay current by giving lectures and hosting journal clubs. Whatever it takes, remember that it’s a marathon, not a sprint, and self-education is useless if it doesn’t continue throughout your career.