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The limits of textbook knowledge

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

open-163975_1280We are in the midst of an epidemic. It now causes more than 40,000 deaths and about 2.5 million emergency room visits in the United States annually, nearly double the number in 2001. It is the leading cause of non-natural death in the U.S. – even greater than motor vehicle accidents. Do you know what it is?

If your mind naturally jumped to gun violence, you would certainly be forgiven, given the recent spate of horrific events and the large volume of media attention they've received. However, the actual answer is (unfortunately) much more insidious: accidental drug overdose, the new leading cause of injury death of Americans. To make matters worse, of the nearly 44,000 deaths attributed to drug overdose in 2013, a shocking 52 percent of these were caused by prescription drugs – in other words, drugs that are theoretically being monitored and controlled by our healthcare system.

To me, the prescription-drug overdose epidemic forces me to consider one of the major challenges of the pre-clinical years of medical school: the fact that the textbook knowledge that we’ve learned about numerous diseases over our first two years can only take us so far in the real world.

For example, we learned all about the measles virus this year; we can recite who is most at risk, how it is transmitted, all of the signs and symptoms that it causes and how it is vaccine-preventable. But do you know how many deaths it caused in the United States in 2013? Zero. (In fact, thanks to the success of the MMR vaccine, most physicians in the U.S. have never even seen a single case of measles in their careers.)

This is not to minimize the severity of measles or to say that we shouldn’t be learning about it in medical school. What it does suggest is that it is far easier for us, as pre-clinical medical students, to learn what we call “illness scripts” – textbook presentations of diseases or conditions, many of which we are unlikely to ever see in our lives – than it is to gain an understanding of the complex, messy personal interplay involved in taking care of patients in the real world.

The problem with the prescription-drug abuse epidemic is that it lies somewhere at an ill-defined intersection of medicine, public policy, law and community health.

Unlike measles, it is a complex problem with no straightforward solution. With measles, I'm as confident as a second-year medical student can be. But with the drug epidemic, I can readily admit that it goes well beyond the scope of my knowledge. But should it? As medical students, we’re going to be putting our names on those prescriptions soon enough – prescriptions that cause 44 deaths per day in this country. We hear often that there are some things that can only be learned from experience. Now that our “textbook” knowledge is expanding during our second year of school, sometimes it feels as though that real world experience just can’t come soon enough!

Nathaniel Fleming is a second-year medical student and a native Oregonian. His interests include health policy and clinical research. 

Photo by PublicDomainPictures

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