Number Crunchers

When I was little, I think my mom really wanted me to grow up to be an engineer or mathematician. She pretty much taught me all the math I learned up until trigonometry, and I’m not sure why she stopped there. I didn’t mind math; type A people usually have a good relationship with it - we follow the rules and get the right answer - it’s simple, and rewarding. However, I was never passionate about it, and I never really understood calculus, despite multiple (some halfhearted) attempts to teach me. I could try blame the illness of my high school calculus teacher and subsequent string of subs and then a new teacher who had never taught calculus. But really, I don’t think I ever cared enough to try and learn it. I’m not really a math person. However, I did emerge from a family and education system that insisted I have not only the ability to memorize tables etc, but a basic understanding of math, at least up through geometry.

A couple weeks back we had a patient on the ward who was on prednisone for cancer symptoms, but really dexamethasone was better in that patient's particular situation. We could just give her the standard dose from America, but people are small here, and she was on a lower than standard dose of prednisone for an America-sized patient. Also, steroids tend to come in only tablets of very small doses here, so if you suggest a large dose, you’re recommendation may be ignored simply because it’s too many pills to take. So to decide on a dose I pulled out a handy pocket reference of equivalent steroid doses. 5mg prednisone = 0.75 mg Dexamethasone. She was on 40 mg of prednisone. In my head, (though it took longer than it should have) I calculated that she should get 6 mg dexamethasone daily. The residents whipped out their cell phone calculators. This gave me time to verify my result on paper, though it seemed like a simple enough calculation. After several minutes, we all agreed. Then a resident called the pharmacy and reported that they had 0.5 mg tabs. 6 tabs twice a day, eh? The resident wrote 3 tabs twice a day. It took several minutes and a return to the cell phone calculator to convince them otherwise.

My residents are smart, hardworking people. When they think critically, they ask insightful questions, and they learn quickly. The longer I am in Laos, however, the more I realize that they have been completely let down by the education system. The above example is one of the standard math knowledge/understanding, not of an abnormally low one. They can’t do simple multiplication or division in their heads. They can’t estimate - they are often off by an order of magnitude or more if asked to estimate something with a more complicated formula. (Like calculating a GFR or an accurate sodium in a patient with significant hyperglycemia.) I’ve never seen one do long division or multiplication on a piece of paper either. And Bryan, who lives in Muang Sing and supports and after-school math/computer tutorial there, reports that he recently found a child cheating using a multiplication table on their computer exercises. These are voluntary after school tutoring sessions - in fact, the kids have to sign up on a waiting list to get in - so there should be no pressure to cheat. However, if you really don’t understand multiplication, and rather have simply been told to memorize it, (Maybe by a teacher who doesn’t understand it either) I guess you might.

How do you take someone who has (through never having been exposed to adequate teaching) maybe never learned simple math, biology, chemistry, or physics, and make them a great doctor? Or a great professional in any field that requires critical thinking about science or math? If you don’t understand basic biology and chemistry, and also math, and some grasp on physics - dimensions, properties of liquids, etc - then how can you understand the pathophysiology of disease? And how can you critically think about treatment? You can’t - you have to rely on algorithmic thinking and protocols. (In American medicine we are recognizing the value of algorithms, protocols, and checklists, but these need to be based on an adequate assessment of the patient and understanding of disease process.) So it’s that much more impressive, then, that my residents know and are learning to make these assessments and critical thinking. If you don’t have a basic understanding of physics, then you need to learn about properties of liquids (blood) in tubes of varying diameters (blood vessels) before you can understand shock, and how septic and cardiogenic shock differ. They are learning these things on their own while we’re trying to teach more complicated concepts. And I think it’s incredible how well they are doing.

It’s also a great illustration of the vital importance of getting at least an adequate primary and secondary eduction - so today I thank all of my friends and readers who are teachers. Sometimes we take your hard work for granted, as if these concepts are so simple that any normal human could almost figure them out on their own. But when we actually think about it, someone taught us all of that information we access and use every day (without conscious awareness we are doing it.) And someone encouraged, or even forced, us to think critically about it and learn how to make a plan to solve a problem. So to my Mom, who taught me almost all the math I remember, and to all the people who taught me biology, chemistry, and physics, and to an education system that required me to learn critical thinking and creative problem solving: Thank you! And to my Lao residents and colleagues who somehow manage to be great doctors and learn despite an often incomplete foundation on which to build: thank you for persevering and working harder to learn things I take for granted.