What’s Gone Wrong in the Training of Doctors and How to Make It Right
As a practicing internal medicine physician and clinical instructor of medical students and residents, I was recently asked to offer some thoughts (dare I say, insights?) on education. As I put pen to paper, I found myself deeply considering the difference between education and formation. As patients stream into my office, I am humbled by the array of deeply personal and vexing medical, psychological, social and spiritual problems I encounter every single day. And when I consider the advice and insight that I offer, there is no small amount that comes not from medical textbooks or journals, nor from lectures or continuing medical education, but instead from simply being human.
Here is a curious fact. Medical schools specifically recruit from among the brightest, most well-rounded, altruistic, efficient students available. Once the schools have accepted their students, they proceed to hammer them pitilessly with countless class hours, innumerable facts and endless tests with predictable results: the students are burned out, anxious and a little stunted. After years of memorizing the arcana of brachial plexus innervation or renal tubular acidosis or the histology of the adrenal gland, the knapsack-carrying, ramen noodle-eating, family event-missing student is “ready” for residency… where they will often get half the time to accomplish twice the workload while coping with ten times the stress. From this crucible, society eagerly awaits the archetypal thoughtful, sensitive, intentional, brilliant doctor who will be there for them in their hour of need.
Where did we go wrong?
Humbly, I think it began when we moved so far away from the intentional teacher (or attending physician) – student relationship (almost on the model of apprenticeship) and diversified teaching between countless faculty among what they perceived as faceless students. Couple that with a firehose of information and little time for students to critically consider, much less challenge it, and you have the crisis of medical education. Now, I know, I know… in this day and age, no doctor knows everything, so to solely rest a student’s education on one doctor’s shoulders may be to shortchange the student. But simultaneously, across the expanse of the basic sciences (first two years of medical school classwork) and clinical rotations (last two years of clinic or hospital based work), there are so many overworked physicians trying to practice and teach simultaneously that even when earnestly trying to educate, they may fall tragically short. From class to class, rotation to rotation, the student fades into the nameless, anxious, pulsating collective shepherded along from one tinny educational milestone to the next without an earnest mentor or seasoned advocate to truly guide them. For apparently the staff as a whole guides and mentors. In other words, when everyone is accountable, no one is accountable.
But from my perspective, to educate – truly educate – one needs to find a small stable of passionate teachers who aim to know the student, hold them accountable, take time to field questions and ask even more, and to demonstrate not only the proper use of medical knowledge, but the nuanced navigation of diverse relationships. Just as vital as when to use antibiotics and when to forego a CT scan is knowing how to listen or how to approach a frustrated patient. It is about mentoring, midwifing, steering, guiding with a deft touch and a caring investment. And those relationships need time: many hours in a day, many weeks in a year for the relationship to flourish, for trust to build, for experience to build upon experience, lesson to inform lesson. In effect, to teach is not about education…it is about formation.
So, in sum, here is my piece about how to form, not simply educate aspiring doctors.
When Winston Churchill reflected on his education, he quipped, “My education was interrupted only by my schooling.” And the southern Catholic author, Flannery O’Connor once observed, “Total non-retention has kept my education from being a burden to me.”
While we grimace at these rather witty, but dark indictments of education, it gives us pause to consider just what it means to truly educate a student.
Education done properly is not simply teaching; it is forming. Formation involves not solely passing along facts & details (though that is an essential component.) Rather, formation means reminding the student to “remember the goal”, not just the facts of their profession. Formation is about culture – a culture of devotion to a craft, of honoring a tradition, of humbly aspiring to shape one’s corner of the world conscientiously. Formation means to instill in students the sense of critical thinking mixed with intuition, efficiency blended with intentionality, equanimity wedded to empathy and to remind students that there at the end of all of their labors lies not a mundane job, but a life-enriching calling. To properly form a student is not to simply give them fish, nor simply to teach them how to fish, but even more, to remind them steadily why they are fishing in the first place.
No matter the ends we seek to achieve in “educating” medical students, we hope in the process that we will form them (even in the smallest ways) into fine human beings. Perhaps it comes in the form of an extra moment or two spent asking the patient about her recently deceased spouse, or making a phone call on a Friday night with a result so the patient won’t fret over the weekend, or even defusing a cantankerous patient with a gentle smile or self-effacing wit. These lessons came from no medical textbooks; they came from being human. For while our aspiring doctors will be appreciated by patients for their astute diagnosis or successful treatment, they will be loved for their listening ear & gentle touch.
Let us never forget that as teachers & educators, we are called to draw upon not just our experience, but our wisdom, not just our knowledge, but our humanity. If we do this – if we really do this – we will not only educate great minds…we will form great souls.
