If you plan for a year, sow rice. If you plan for a decade, plant trees. If you plan for a lifetime, train and educate people.
When students learn about the human side of medicine, the community of patients is the ultimate beneficiary. Taking my clue from Chaim Potok (chapter 18), I sometimes say to students:
All beginnings are hard. There are frustrations to learning. You can’t understand everything immediately, and so much bears repetition. You are learning a new way of understanding illness and what it’s like to be a patient and a physician. More and more, as you gain knowledge and experience, you’ll be on your own. Experience re- quires learning at every opportunity and integrating what you learn with what you already know. That’s not easy at first, and the responsibility of the teacher is to teach you how; your responsibility is to recognize the importance of the process.
A teacher needs to be warm, welcoming, encouraging, and perceptive. Teaching touches “the raw nerves of faith”1—values, in other words. As teachers, we need to recognize the sophistication of what we do and try to see through our students’ eyes. When it is appropriate, a good physician will say to patients, “You’ll be all right soon.” To students, a good teacher will say, “Well intended and focused properly, you’ll soon learn what you need to know to be a good doctor.” The partnership between student and teacher sustains the excitement.
If you want to learn a subject, find a teacher. And if you really want to learn a subject, become a teacher. The opportunity and position we have as teachers of medicine give us the responsibility to do it well. Teachers not only transmit new information, but they also model ways to approach prob- lems and develop relationships. By their example, they can teach bad, de- structive lessons or wonderful, valuable ones. We need to honor good teaching no less than good cardiac surgery. We need to recognize bad teaching also, lest silence be taken as endorsement. I encourage my stu- dents to identify and reject bad teaching.
One of my former second-year medical students told our tutorial group this story.2
A 45-year-old man was hospitalized because of neck pain that had been present for a few weeks, but worse in the few days prior to admission. When I examined him, I noticed weakness of the shoulder muscles and numbness in his entire arm. The rest of his examination was normal, except that his body was covered with tattoos. Two days later, when I presented the patient and his story to my instructor as a patient with a possible spinal cord lesion, all the physical findings had disappeared. The instructor felt that the patient had been malingering, was critical of me for accept- ing the patient’s story without suspicion, and told me and my eight classmates: “Don’t trust people with tattoos” and “Don’t trust all your patients’ stories.” I felt humiliated. Initially I had felt that the patient and I had a good relationship. But after that I felt embarrassed that I had been taken for a sucker, hurt that I had been betrayed by the patient, and confused by the admonition about trusting patients. I had always believed what the patient said.
Bad teaching! Worse yet, uncritiqued and uncorrected, the teacher had given his students useless and potentially harmful information, and he had set a bad example of how to relate to a patient. But even bad teaching and bad modeling can become teachable moments. Here are some of the bad lessons and some better alternatives.
Bad lesson 1: “Don’t trust people with tattoos,” a prejudiced statement, no more valid than an ethnic slur, and no more useful clinically either. When our view of people is tainted by prejudice, we deny ourselves the op- portunity of seeing them in all of their dimensions. When we as physicians define someone too narrowly, we deny ourselves creative ways of looking at them and their problems, and we may deny them a correct diagnosis and remedy. People with tattoos get sick.
These are better lessons:
• His findings cannot be explained by the realities of neurological anatomy, and so we should suspect malingering, but also the psychiatric entity called “conver- sion reaction.” Both suggest psychosocial issues.
• That the findings at the time of his first examination cleared after two days should also raise the question of a conversion reaction or malingering.
• Conversion reaction and malingering are possibilities that should be included in the differential diagnosis of any patient with the problem statements “muscle weakness and sensory loss,” but they are not the only diagnostic considerations.
• For all these reasons, and not because he has tattoos, consider conversion reac- tion and malingering.
Bad lesson 2: “Don’t trust all your patients’ stories.” There are better les- sons:
• You are better off trusting the patient until proved wrong. From a patient’s per- spective, there may be nothing worse than not being believed.
• People who feign illness or have conversion reactions may have concurrent or- ganic illnesses.
• Like this problem, there are other illnesses with very dramatic moments that re- solve spontaneously and have an organic cause—renal colic, seizures, and tran- sient cerebral ischemic attacks, for example.
• Sometimes the best test is the test of time. Rather than ordering more tests, which may be costly or uncomfortable, allow some time to elapse if no harm can occur from the delay. As in this case, the passage of time helped to clarify the di- agnostic issues.
• Given that this person was not telling the truth, ask, “Why not? What’s going on in his life?” The answers to those questions may provide useful information.
Good teachers turn a bad experience, or a bad question, into a good one, and they often expand the question. The student’s recounting of the pa- tient’s story and his own experience with less-than-ideal teaching allowed us to address other issues:
• What about the long-term management of this patient? The physician can es- tablish an alliance with this patient without saying, “I’ve got the goods on you.” Recognizing a moment of dishonesty gives us the opportunity to confront cer- tain nonproductive ways in which patients deal with life and help them to dis- cover better ways of handling things.
• What is it like for an experienced physician to face being “taken for a sucker” by a patient? By helping the student address this question, I can point out that such an event happens only rarely, but that it is part of the gamut of transactions that we face in medicine.
• As a group, we looked at what it is like to “be on the spot” as a medical student and to “need to look good.” While we strive for perfection in practicing medi- cine, we are called upon to make so many decisions in the course of a profes- sional day that some of them are bound to be imperfect. Such decisions are rarely of consequence, but occasionally we may cause harm. We have to be able to deal with that emotionally.
The student told of one further frustration. His teacher had said, “It is unethical to talk to anyone outside the profession about professional expe- riences.” The consensus of the group was that we can share dilemmas with trustworthy confidants, so long as we preserve confidentiality.
Good teachers teach not simply how to accumulate experience, the easy part, but also how to learn from experience and integrate new experience into judgment, discarding methods of diagnosis and treatment that do not work. Good teachers show that every transaction in medicine is a teach- able moment and how to squeeze everything possible out of those mo- ments. Eleanor Roosevelt saw that “there is no experience from which you can’t learn something.”3 Pirke Avot, a collection of rabbinic teachings, de- clares, “Who is wise? The person who learns from everybody.”4
Good teachers appreciate that different people learn in different ways and start from different places. Years ago when I started to do darkroom work, I asked a friend, a skilled photographer, to give me some pointers on darkroom technique. He so overwhelmed me with information that it was years before I returned to the darkroom. In contrast, baseball manager Whitey Herzog said of Casey Stengel, his mentor, “Like the best teachers, he gave you the big picture in little doses.”5 Good teachers discard methods of teaching that do not work, start where the student is, and speak the stu- dent’s language.
TECHNIQUES OF GOOD TEACHERS
No two patients are alike. No illness is exactly the same in two patients. No two patients have exactly the same experience with the same illness; their feelings and how they deal with the illness are different. Good physi- cians accommodate these differences. Good teachers accommodate the differences in the ways students learn. The teacher’s ultimate goal is to teach students how to be their own teachers and how to teach their stu- dents, their patients, and their colleagues.
We teach from personal experience. At the beginning of their careers, med- ical students have scant professional experience. Nonetheless, each may have experience as a patient, as the family of a patient, in various relation-ships, jobs, and careers, in dealing with life’s dilemmas; and experiences with teachers, good and bad. We can learn a great deal from our own expe- rience, as chapter 5 shows.
We teach in different settings. As with teachable moments, there are also many teachable settings—at the bedside, in the clinic or office, and during formal lectures and meetings. We can create teachable moments and teachable settings in practically every clinical encounter.
We teach through stories. As an intern, I rode the ambulance to the scene of a one-car collision in Minneapolis; the car had rammed a tree. The po- lice officer at the scene informed me that when he had arrived, the man got out of his car and “started swinging,” and so he handcuffed him to the steer- ing wheel. I was preparing to inject the man with a sedative when one of my teachers wandered by, surveyed the situation, and offered his opinion: “I wonder if he’s having an insulin reaction. It’s 5 p.m., about the time certain kinds of insulin reach their peak activity, and maybe he’s late for a meal.” Instead of an injection of a sedative, I gave him an injection of concen- trated sugar, and his confusion cleared. From that experience, I learned to suspect an insulin reaction whenever confusion is present and that the confusion can be subtle.
Years later, I was speaking with a visiting insurance agent just before lunchtime. He kept asking me to repeat myself because he did not quite grasp what I was trying to say. “Do you have diabetes?” I asked. “Yes.” “Are you having an insulin reaction?” He was. I saw that he immediately got food. As a medical student, I had learned that the symptoms of hypoglycemia included sweating, rapid heartbeat, and confusion. But whenever I have taught about insulin reactions, I tell these stories in order to help students become more perceptive in detecting hypoglycemia. Stories are far more effective than teaching that “X percent of patients with insulin reactions have a change in mental status.”
We teach by going from the general to the specific, the specific to the general,
and the narrow to the broad. As teachers we ask, “What can we generalize about this case? What is unique about this case?” By going from narrow to broad, we stimulate ourselves to learn even from the mundane. It is not a big step to learn from each case. During one week of my residency, after ex- amining my sixth patient in succession with abdominal pain from alcohol abuse, I asked myself, “Though it’s likely that this patient, like the other five, has alcoholic gastritis, a common diagnosis, why doesn’t he have mesenteric artery insufficiency, a rarer cause of abdominal pain?” The exer- cise stimulated me to read more about the subject in medical textbooks and journals.
We teach by analogy and comparison. We teach by extracting the essence, applying what we have learned to other cases, and recognizing the similari- ties and the differences among them. Using the actual case, we enlarge upon the disease, the symptom, or the problem. We discover what more we need to learn. We ask, “What lessons do we learn from this case that are ap- plicable to a patient not only with the same illness but with other ones? What effect does a difference in age have? What effect does the absence of a supporting spouse have?” We ask, “What are the unknowns? Is this case ex- actly like another one?”
We teach by seeing patterns and making connections. Then the “bells go off” the next time we see those associations. During residency training, I en- countered two patients with severe abdominal pain, each following a simi- lar pattern: a first period of pain, followed by a “silent period,” one without pain, and then more severe pain and circulatory shock because of massive irreversible bowel injury. From the medical literature, I discovered that other patients with this unusual illness, embolus to the superior mesenteric artery, followed a similar pattern. The clue to the diagnosis was to consider it when acute abdominal pain occurred in a patient with atrial fibrillation and not be deceived by the absence of pain during the silent period. The next time I saw a patient with this combination of findings, I knew what to do before the bowel was irreversibly damaged.
We teach by keeping an open mind about different ways that diseases present themselves and relationships between problems and their treatments. We contin- ually ask, “Is there another way to look at this?”
We teach by studying mistakes. We look at both good and bad practices.
We ask, “What can go wrong in diagnosis and treatment?” Writing about how he perfected his craft as an actor, Theodore Bikel observed that “the critique that follows each piece can be very helpful. So can offering critique to others, as it hones your analytical senses.”6 By defusing the threatening aspect of critique, we turn mistakes into opportunities to learn.
We teach by studying principles of reasoning simultaneously with information about specific problems and diseases. Table 23.1 provides examples.
We teach by reinforcement and repetition. Especially during the early years of training, students need to hear a lesson more than once and in different contexts.
We teach by observing the interaction, by writing, by video- or audiotaping, and by role playing. Though each has its advantages, they all can be critiqued, reread, or recomposed. I often ask my students to “write it out, as if you were talking to him,” and then we critique what they have written and how they say it as they play the doctor’s role. I also tell my students that
Teaching Principles of Reasoning Simultaneously with Information about
Specific Problems and Diseases
I will closely critique the quality of their written work because I believe that how they write reflects the clarity of their thinking.
We teach by modeling. I know a master trumpeter who invites his students to his performances and encourages them to watch others perform. One of my colleague’s students told me, “I was in a tough situation, and I asked my- self, ‘What would Bill [his teacher] say in this situation?’ ”
And so a teaching encounter may integrate many of these principles.
• One student presents a case, the summary of the patient’s story (the history) and the physical examination.
• While the student presents the story, another constructs a problem list for all to see.
• The students and the teacher critique and sharpen the precision of the problem list by asking: “Is the problem list complete? Have all the problems been prop- erly named?”
• The students and the teacher validate and enhance the history by returning to the patient for additional details to answer the questions defined by the above steps. The teacher models the process by interviewing the patient in the stu- dents’ presence.
• The students and the teacher continue the discussion by talking further about the patient, the diseases, the problems yet undefined, issues of the doctor-pa- tient relationship, and tactics for diagnosis and treatment.
• And then they ask, “What did we learn?”
In each of these steps, the teacher can see where students are in their com- prehension and reasoning and move them along at their own pace. “A stu- dent has the right to be challenged,” one student wrote.
The best teachers like what they are doing. And they like their students.
The best teachers understand their subject. They know the best techniques for teaching it and can describe them. They teach with clarity of presentation, purpose, and intent. They ask clear questions and follow with “Do you un- derstand?” From medical school and postgraduate residency training, I still remember that whether the feverish child looks ill is often more important than how high the temperature is. I also remember not only who taught me these lessons, but when and where I learned: the “silhouette sign” in chest x-rays, how to interpret a blood sodium level, the differential diagnosis of pulmonary edema, and the best way to examine a thyroid gland.
The best teachers use common sense, common nonphysician sense. Technical knowledge adds to thoughtful decisions, but rules can sometimes get in the way of original thinking if we do not understand where they apply. I teach, “Never do anything that violates your common sense.” The best teachers use their “personality.” They are part of their message.
“Preaching,” a minister friend and patient recognized, is “the bringing forth of truth through personality.” One need not be garrulous, but simply genu- ine. Good salespeople sell their product by selling themselves.
If all these qualities of a good teacher seem familiar, it is because they are qualities of a good physician. While I do not regard my students as patients, I recognize that, as a teacher, I use many of my physician skills. There is one more analogy.
The teacher-student relationship is like the doctor-patient relationship. One way to explore the doctor-patient relationship is to use the teacher-student relationship as a model. I ask students, “What are you, as a student, entitled to ask of your teachers? What are you, as a patient, entitled to ask of your physician?” I urge them to examine ways in which the two relationships are similar. I also ask them to compare our relationship at our first session with our later one, well into the semester, and to see how time enhances both re- lationships. The analogy works.
The best teachers develop a relationship with their students. With the rela-tionship comes trust, respect, candor, and consistency. You cannot learn from someone you do not trust, and teachers need to trust their students. Continuity provides the teacher with awareness of students’ own stories and fund of knowledge; teachers can encourage students who are frustrated or moving slowly because they know why. The best teachers are accessible and approachable.
PHYSICIANS LEARN FROM THEIR PATIENTS
Our patients are our faculty. Not from a teacher or a text, but from pa- tients, I learned that pneumonia and congestive heart failure can cause confusion and that patients with coronary artery insufficiency may not have chest pain but only shortness of breath. I have also learned big-picture lessons: that people can cope with illness in many ways and that almost any drug can cause almost any side effect. Better than any text, patients teach us various ways that illnesses manifest themselves. From patients I learned what it is like to be a patient. From a friend with cancer, I learned that being examined in a gown “dehumanizes” her, and so she now negotiates with her physician to examine her in street clothes.
From patients I also learned what not to say. We cannot possibly choose every word, and even ordinary transactions can be complicated. But we can learn from every transaction. To a young patient with pancreatitis, alcohol- ism, depression, and seizures, I said, as encouragement, “Our goal is to get you back to where you were [in life, before this acute illness].” But he re- sponded, “I need acceptance for where I am.” He explained that because of his diseases, multiple medications, and multiple physicians’ appointments, he could never get back to where he was, and my statement simply gave him another unattainable goal. A better goal, he suggested, was to get to “as good as it can be.” To comfort someone after the death of her spouse, I said, “I know how you feel.” “You can’t possibly know how I feel,” she responded with a hint of outrage. I learned quickly. Now in similar situations I say, “I can only begin to appreciate how you must feel.”
From patients’ stories, we learn that illnesses, acute or chronic, poke along sometimes, and when the answers became more clear, we wonder, “Why didn’t we figure this out sooner?” But that is the way life is in general: Decisions poke along, and only toward the end do we see the solution that was staring us in the face and gain new insights.
From patients, we learn that congestive heart failure sometimes persists because of ongoing dietary salt indiscretions, controlling the blood sugar level in diabetes sometimes is difficult because the patient cannot see the markings on the insulin syringe, and controlling high blood pressure some- times fails because the patient cannot afford the medicine and is too em- barrassed to say so.
We learn from families, who are often far more expert on the subtleties of an illness than their physicians. An 80-year-old woman’s children detected a subtle change in her mental status that I had overlooked. That led to a di- agnosis of subdural hematoma, a blood clot pressing on the brain, curable with surgery.
Sometimes we see successes and extraordinary recoveries that we can- not explain. From patients, we learn why. An initially grim prognosis was inaccurate because the diagnosis was in error, the problem was not so pre- cisely defined, or because some people simply defy the odds. The person whom the physician feared discharging from the hospital managed quite well because the patient was more resourceful than the physician thought.
A giant leap in the physician’s maturity occurs when we make the transi- tion from learning about our patients to learning from them. An undergrad- uate discovered early that “the patient’s illness provides a focal point for a new learning experience in which the physician and patient use their expe- riences to learn from each other.”
Of the evolution of the teacher-student relationship and its parallel with the doctor-patient relationship, an undergraduate wrote:
Before taking this seminar course, I had no idea who you were or anything about you. . . . Even though I am still wary speaking in class, I have become more comfort- able because you value everyone’s opinion and story. You ask probing questions and seem interested in what everyone has to add to class discussion….I feel the job of a teacher is to guide students along their journey of learning. . . . Teachers take on many forms throughout an individual’s life. Some may be mentors, educators, friends, advocates, counselors, or encouragers…. [The student-teacher relation- ship] is one which concentrates on personal growth…. One must realize the limi- tations a physician and teacher are working under as well as student and patient. Both professionals must be very observant and recognize subtle clues that lead the teacher to a “teaching” diagnosis and the physician to a “health” diagnosis.
All physicians are teachers. Not all physicians teach students, but all teach patients. A third-century Chinese proverb declares, “If you plan for a year, sow rice. If you plan for a decade, plant trees. If you plan for a lifetime, train and educate people.”7 We are teaching how to learn and how to be- come our own teacher. Part of the Hippocratic Oath is our obligation to teach. Each of us—physicians, teachers, students, and patients—has much to teach; we need only examine our experiences. The goal of a good teacher is to help make the lessons explicit and pass them on. Being a teacher has all the qualities and responsibilities of being a physician: the intensity, the continuity, the relationship—and the satisfaction.