Posted by: Witch Doctor | January 3, 2008

Where’s the femur?



The Witch Doctor never, never, ever, has come across a qualified doctor (medical practitioner) who does not know the whereabouts of the femur (assuming, of course, it is still attached to the patient).

Lack of knowledge of the whereabouts of the foramina of the skull – yes.

The femur – no.

All qualified medical practitioners know the whereabouts of the femur.

All of them.


Believe me.




If The Witch Doctor came across a health care professional unsure of the whereabouts of the femur, The Witch Doctor would assume that health care professional was not a qualified medical practitioner, whether or not they looked like a doctor, dressed like a doctor, called themselves a doctor, or behaved like a doctor.

If a qualified medical practitioner truly did not know the whereabouts of the femur, The Witch Doctor would assume the individual was in the midst of some kind of psychiatric crisis and required help, or the conversation was taking place in a non English speaking nation.


Patients should not be given the impression that doctors do not know the location of this major long bone.


However, this clip does raise some valid questions regarding problem based learning (PBL) and whether the acquisition of “soft” skills such as communication are now being emphasised to the detriment of “solid” medical training.

And this is certainly worth debating.

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  1. Speaking as someone who teaches on (and runs bits of) a PBL medical course, the term “PBL course” covers a wide spectrum of ways of doing things.

    For instance, some courses are graduate-only, which students generally thrive in PBL settings and are often very un-keen to sign up for several more years of sitting in lecture theatres being talked at.

    Some courses use only scientists or medics as PBL tutors, include basic lectures of various kinds, retain “classical” DR teaching, run lab classes on pathology / physiology / pharmacology, and link material thematically (e.g. doing lung function practical classes at the same time as respiratory cases etc). That is what I would call “pragmatic” (well designed?) PBL.

    IMHO the main difference in a course of this kind from the old didactic system is that the central thread that tries to “visit everything judged important at least once” is based on the PBL scenario content rather than the lecture content.

    But, as I said, PBL is not always like that. Other PBL courses I know of variously have librarians or social scientists as the PBL tutors, have no lectures, and don’t “link” labs to cases, or even have no lab classes at all. These are what I tend to call “fundamentalist” PBL.

  2. Thanks you for visiting again, Dr Aust.

    I think I am correct in saying these first PBL medical courses (McMaster) were designed for graduates and, as you say these students responded very well. My understanding is, though, that this university has since changed its tune about some things.

    The Witch Doctor was around in the early days of a “fundamentalist” PBL being set up from scratch. Words like “lecture” “didactic” and “rote learning” were regarded as obscenities although occult lectures soon appeared again – they were given another name, though, and everyone pretended they weren’t lectures! I think most “pure” PBL courses eventually creep into a hybrid form and this is probably better for most students.

    Being a student in the days of didactic teaching was always a pain in the neck for The Witch Doctor who has always learned using PBL methods and still does. Nevertheless, I always think this might be a difficult method for those with very tidy, organized minds (unlike The Witch Doctor)!

    One of the main concerns I have with the modern medical student curriculum, PBL or not, is the concept that there are some things you don’t really need to know much about, therefore they should not be taught. Surely the human brain is like an under-utilized sieve. Scanning over information once without making any effort to learn or retain, seems to me to be a very important part of the wide experience necessary for making future decisions. This facet is so lacking in protocols and aspects of competency based training. The Witch Doctor’s name for this is “a feeling of knowing.” I’m sure the psychologists will have a better term.

    e.g. I think once having read the names of the foramina of the skull, seen them, and then immediately forgotten all about them is much better than pretending they don’t exist! But for pity’s sake don’t examine on them unless preparing to be a neurosurgeon.

    Dear me, we witches always get talkative as the witching hour approaches!

  3. Hadn’t been by for a while so had not seen your comment, Witch Doctor.

    Interesting idea about “read it all once”. I have some sympathy for this since “Hmm, I’m sure I remember once read something about this somewhere” is certainly a mindset that has worked for me. Also, wide reading usefully reminds people that you can never know everything.

    My impression is that the medical students always read far more than we tell them to, actually. The real difficulty in early years PBL, I think, is getting them to grasp that they need to spend time reading enough about important “deep background” (at least as they see it) stuff that they don’t like, like the basic physics of gas diffusion (cf alveolar gas exchange). They would far rather be trawling the path book for lots of detailed classifications of disease X (which odds on will have been changed by the time they reach FY1). You also tend to have to keep slapping them back from boring in relentlessly on “tests and treatments” , which means the crusty old tutors like me grumbling “talk about pressures” or “but what pathophysiological things does that treatment address and why does it work?”

    The primary worry among the scientists (and among a lot of the hospital folk, in my experience) is that if you have solely GP PBL tutors right from yr 1 (as happens at a couple of UK schools) then that sort of thing could well not get done in some groups (though it obviously depends on the tutor). There are certainly people who argue “well so what, that’s no different from groups run by scientists where they never talk about social deprivation”. But I have always had the suspicion that you can pick up the social science stuff relatively easily by a combination of reading, wise colleagues and (invaluable) life experience. Whereas I reckon you have less chance of working out alveolar gas exchange later when you don’t have an understanding professional explainer to hand. But then, given what I do for a living, I would say that.

    I had to laugh when I saw what you wrote about the inception of PBL courses – I too am old enough to have been there, though I was a youngish lecturer at the time (this was the mid 90s).

    There were some priceless moments, as the start-up mindset in certain quarters was definitely pretty fundamentalist. I clearly recall going to a compulsory “tutor training session” where a dozen of us (bioscience academics) were herded into a room and then made to “pretend PBL-brainstorm” a case scenario which was about a young lecturer’s attempts to find the right room to give his tutorial in! Two people walked out as soon as they had read it, muttering “Mickey Mouse !x*!**!t”. The rest of us hung in there until the end, at which point one of the people in the room revealed she was actually a behaviourist, had been analysing our “group dynamic” and was now going to tell us how we had interacted. This prompted half the remaining people to throw the paper on the floor and storm out. I stuck it out in a spirit of sociological curiosity, but it was pretty painful. If I ever end up in group therapy I will obviously have had a head start. Over the years I have come to the conclusion that there are two kinds of “Medical Educationalists” – a minor population who can speak English and are quite useful, and a bigger population whose primary purpose is to talk in code so dense that no-one else can possibly understand it, thereby preserving their rols as sort of “guardians of the faith”.

    Talking of “tutor training”, it now has specialist education types who do just that. Apparently nowadays it is easier to get clinical PBL tutors to go to 1/2-day “training events” than to get the science academics to go, but then the clinicians are getting a half-day away from the sharp end and their CME points.

    The daft naming was also very characteristic of the beginnings of PBL in the UK – as you say, “Colloquia” or “Theatre Events” for lectures, and the like. But where I work the experience has definitely been one of regression to the (hybrid) mean.

  4. I well remember the “tutor training sessions” too, Dr Aust. Our “test” was to build a wall. I had a distinct advantage on that occasion, because I had been going to night-school for bricklaying classes, and couldn’t decide whether to crow a bit or keep my “skills” secret. I think I kept them secret. I don’t think we had any psychologists experimenting though – or maybe we had and I was too thick to notice!

    We were inundated by GP’s in the early days – it was said they were always willing to participate because they received payment whereas hospital staff didn’t. I don’t know whether this is still the case. There is no doubt the predominant GP input skewed the balance a bit towards “The Univeristy of Life” approach in the early days.

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