This article was published in Scientific American’s former blog network and reflects the views of the author, not necessarily those of Scientific American
In just under two months, I will be making two big transitions as I begin life as a resident. The first and obvious change is from student to doctor. The second doesn’t get the same spotlight, but might be just as important: from student to teacher.
Residents play a vital role in medical student teaching. With medical training like an apprenticeship, it is the residents with whom third-year medical students often spend the most time and soak up knowledge and norms. I can attest to this. An enormous part of my education as a medical student came from residents, with whom I worked most closely day in and day out. In fact, studies have estimated that about one-third of medical students’ learning is from residents, and residents in turn spend a full 20 percent of their time teaching. Now, as I prepare to start residency myself, my own residency contract identifies the resident-as-teacher role as one of our top priorities, secondary only to patient care: “Residents are expected to participate fully in the educational and scholarly activities of their program and assume responsibility for teaching and supervising other residents and students.”
I’ve been thinking a lot lately about what it means to be a teacher; this role will be new for me. How can I help cultivate creativity and empathy, and not snuff out qualities that were already there?
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I recently re-read the article “Curiosity” by Dr. Faith T. Fitzgerald, former dean of students at the University of California, Davis, School of Medicine. It’s a wonderful piece, and I was so moved the first time I read it that I wrote a post on it during my first year of medical school. What I found interesting was that while re-reading it three years later, a new part caught my eye; it was something I hadn’t focused on in my first review.
“How is curiosity suppressed in medical students and physicians? It is. I have discovered, in nonclinical settings, that students who, on the wards, seem totally without curiosity or culture–dolts, in short–were, in their private worlds, avid poets, artists, musicians, and craftspersons of exquisite skill, vitally interested in a wide range of topics. They just did not think it wise to let anyone know because they had received a message from housestaff, faculty, or peers that interest in anything other than purely biological medicine was inappropriate for a medical student.”
It resonated in a harsh way. As a third and fourth-year medical student, I sometimes felt like a dolt on the wards. The thing is – and forgive my self-assurance here – I don’t think I’m a dolt in real life. Just like the students Dr. Fitzgerald described who had interesting lives outside of medicine and suddenly became dull on the wards, so, too, I could relate.
Sadly, the trend of medical students losing something during their training is widely documented. Many have written on the decline of empathy during the third year. But it’s more than that. There’s the decline of creativity, too. In a recent New England Journal of Medicineperspective, one of our most celebrated teachers at Harvard Medical School, Richard Schwartzstein, rightly lamented:
“Typically, students enter medical school idealistic, eager to improve the human condition, and excited about becoming doctors. And then we do various things to change them.”
What exactly was done to me? Reflecting honestly on my medical education, I’ve had some truly outstanding teachers and some less than stellar ones (with fortunately more of the former), and many in between. But sometimes the most negative experiences for me weren’t the result of any particular individual, but a culture that treated me in certain ways – that set certain expectations for who a medical student was and how she should be treated, and then acted to mold me toward those expectations. It was these unspoken pressures that made me feel my most dolt-like – or at least, didn’t do much to counteract it.
Now, I don’t think I fundamentally changed, and I’m glad about that. But I did often experience the cognitive dissonance of feeling like a different person on the wards from the person I considered myself outside of medicine – not to mention the person I had always imagined myself being.
Here are a few key trends that I feel contributed. I’d emphasize none of the below is universal, nor do I pretend there weren’t things I could’ve done differently as well. But these are some problems I picked up on the weaker teaching services that I feel negatively impacted medical student development. I’ll discuss the positive experiences after.
1) Valuing the answer over the thought process.
The way to “test” medical students’ ability on these services was the tip-of-the-tongue answers. Residents would ask us questions, and what mattered was if I were able to toss out the correct answer akin to being on Jeopardy. The problem was that this led to more trivia than the much more challenging – and much more important – process of clinical reasoning. The latter was what I really wanted to learn. And if you tried to reason it out, you would get cut off, because that’s not what they wanted to hear. The result was a culture that focused on buzzwords and single right answers, and incentivized proving you knew something over working out the steps toward getting there.
2) Placing much more emphasis on how we talk about patients than how we talk to patients.
This was a big one for me. My medical school had a strong curriculum on patient communication during the first two years, and when starting my third year, I was eager to finally get to care for actual patients. And though I did, a demoralizing undercurrent was how much of it seemed to be done from the other side of the door. On these teams, I noticed much less face time with our patients. Moreover, this was not what medical students were evaluated on, reinforcing a message that patient interaction was a less important part of patient care.
Instead, a premium was placed on was how we talked about patients. How we called a specialist consult; how we “presented the case” on rounds – our evaluations hinged far more on these than on being able to explain to a patient what was happening with her illness. And so though everything we were doing was about the patients, they felt oddly secondary, oddly detached.
3) Not recognizing that different learning styles and different personalities can be just as effective doctors.
Some people are on the quieter side. Some people are loud. Some people think before talking. Some people think by talking. Nothing here is revelational; people have different learning styles and different personalities. No single one is fundamentally tied to being a good or a bad doctor. But on these weaker services, medical students’ personalities were often policed as much as their medical ability. Our feedback was filled with commentary like: Be louder; be quieter; be more assertive; be less pushy. Some of my friends even got comments on their facial expressions (e.g. “you look bored on rounds“). But of course, this is silly. You can be a great physician and have a completely different personality or learning style.
Strengths-based organizations make jobs fit around personalities and interests rather than the other way around. Medical training might want to take a similar cue, rather than trying to mold students into one concept of what a Good Medical Student (and by extension, good future physician) looks like.
4) Treating learning as linear.
Medical training is a lesson in graded responsibility. Start with faxing the outside records, and maybe you can work up to admitting a patient. Start with pushing the bed down the hall, and then maybe you can suture. Hold the retractor steady, and then someday you can lead the family meeting. The way to get increasing responsibility on the wards was to demonstrate some sort of competence. The problem was, sometimes the things we started on were not predictive of – or all that related to – the other activities we were interested in. After all, one can be a skilled secretary and a just okay physician, or vice versa. Learning isn’t linear; these correlations just don’t hold.
As a result, assigning graded responsibility based on these measures places arbitrary limits on what students can or cannot learn. It also overlooks backgrounds that can benefit the team (e.g. some of my classmates had PhD’s or entire other careers before medical school). A friend once joked to me that after letting a retractor slip, she wouldn’t be allowed to do anything else of value that week. What was sad was how much truth there was to that.
5) Forgetting what is common sense, and what should be taught.
Early on in my third year, a resident asked me what can be used to treat a particular type of infection. I had taken the boards a few weeks earlier, so I scanned my brain for an antibiotic that applied. I said it. The residents laughed. Turns out, it was technically right but practically wrong (as a very powerful antibiotic, it would never be first-line). I know this now. It was a perfect example of where book knowledge needs to be supplemented by clinical experience.
But sometimes residents forget this. The same goes for practical norms. Every rotation (e.g. surgery, psychiatry, ob-gyn) came with a new set of logistical expectations, and I can’t overstate how much more effective I was when my residents made these explicit. The alternative was a culture where medical students were viewed as a source of expected incompetence; the punchlines of jokes they weren’t privy to.
One can imagine how these trends, pushed over and over, can take a toll on the outward expression of curiosity, and instead make for an army of dolts.
Then I thought about some of my best teachers, and what made them so good. The compassionate internal medicine resident who not only served as a role model in patient interactions, but who also recognized the effects that witnessing mortality might have on students, frequently checking in on how we were doing. The anesthesia nurse who patiently taught me how to place IV’s, going over each step meticulously, and not judging or pulling the equipment from me when I did not succeed, but instead offering specific tips that enabled me to get it right the next time. The intern who gave us third-year medical students full responsibility over our patients, letting us direct the conversations and treatment plans, but never absent, always sending resources and offering feedback to help us improve. And there were many more.
What did they have in common? They were patient. They focused on what matters. They put the patient at the center of care. They created cultures where everyone was respected and open communication was welcome. They were enthusiastic about having medical students active and involved. And the educational glue: they made medical students feel autonomous yet supported at the same time.That’s how you learn; by doing, supplemented with regular feedback. That’s how you get better.
These wonderful teachers shaped me. I could not be more grateful for them.
In less than two months, I will be a resident, and we will have eager, excited, and nervous third-year medical students join us. As a resident, I’ll have the enormous privilege of being in a position to play some part in shaping their development into physicians. I’m humbled to even be in such a role. I am nervous, too. How can I help cultivate curiosity and empathy, and not smother what was there? How can I help someone develop into the kind of doctor she wants to be? And how can I do this, given perhaps the greatest obstacle of all – the constantly competing time constraints and pressures of being a resident?
I’ll be the first to admit I have no idea how to get there, and I imagine the beginning of my residency will have a predominant focus on the student-to-doctor transition before teaching can become a priority. But this is what I ultimately want. I want our patients to be at the center of everything we do. I want an environment where people feel comfortable being themselves and are free to ask questions, have emotions, and disagree with those more experienced. I want the focus to be on education over evaluation. I want to remember that at every stage of training, doctors are still learning, and I want to appreciate what medical students can teach us in addition to what residents and attendings might teach them. I want someday, no matter how long it takes me, to be able to emulate the wonderful teachers I had. I want to not destroy what was there in the first place.
To the medical students with whom I will soon have the privilege of working, perhaps you can help me. I genuinely cannot wait for the opportunity to work with you and share in your enthusiasm and curiosity. I look forward to learning together as we care for our most important teachers of all – our patients.
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For all the teachers – residents, attendings, nurses, and others – who spent time with me, taught me, encouraged me – I cannot thank you enough. You are my role models.
I recognize there are people who devote their lives to teaching, both in and outside medicine. I’d love to hear from you! Feel free to share advice in the comments section. I promise I’ll take it to heart.