The Physician as Teacher: Final Reflections

When I began this selective, I was a senior medical student, nearing the end of my training. I had many tools in my tool belt: I could take a history, I could generate a differential diagnosis and a tolerable management plan; I even knew exactly what time of day I needed to plan to get coffee based on how many hours I slept the night before. I had learned the CanMeds roles and felt I could embody a physician beyond the medical expert, having learned to advocate, communicate, and collaborate effectively; I thought I was ready for residency. I was wrong.

The past month has been an opportunity for continuous reflection and learning, not only about myself, but about what it really means to be a doctor. In my blog posts I have tried to chronicle my journey of learning about how doctors learn, how we think, and how a curriculum might be best designed to capture this most effectively. The last week I took a bit of a 180 degree turn and spoke more about the Art of Medicine and how this might be effectively taught in the curriculum. Throughout this reading and reflective writing process, I have had the absolute pleasure of working with Dr. Ho Ping Kong in his clinic, absorbing (sometimes without realizing it) his fundamental lessons of compassion, integrity, connection, and humility. I have come to realize this month that there is a quality physicians should be cultivating which I feel is not encompassed by the CanMeds roles, and that is one of Teacher.

The physician as Teacher can be described in several dimensions. First, with our patients and their families: beyond communicating information, teaching is about bridging a gap in knowledge. It requires an ability to understand where the person you are teaching is standing, identifying their fears and confusion, and addressing all of these things while ensuring the information is provided in a way that will be understood and remembered. It requires compassion, patience, and empathy; effective teachers understand when somebody will not be able to hear and remember (i.e. when a relative is at death’s door, or they are in pain) and are sensitive to the changing landscape of a patient-doctor interaction.

Secondly, physicians are teachers of medical learners. Several schools have programs in their residency programs for ‘Teaching Residents to Teach’, and yet these are not mandatory programs. While it is true that not all physicians will make this a focus of their career, nearly all of us will contribute to the training of future doctors and have not been given the skills or tools to do this effectively. Many of the principles I have addressed in my blog posts about teaching and learning strategies, as well as topics I was not able to address including physician self-assessment and feedback are integral to effective teaching, and yet the majority of physicians know nothing about them. Again, in this case, beyond the technical knowledge and medical education principles, good teaching requires an increased ability for physicians to recognize their own abilities and the difference between them and their students before they can effectively bridge that knowledge gap.

By incorporating the physician as Teacher into a framework such as the CanMeds roles, it would be a mandated expectation for physicians to be competent in the fundamental areas which would allow physicians to be effective teachers. These include qualities I've highlighted in my previous posts about critical consciousness and self-awareness, as well as an ability for physicians to practice reflective medicine and accurately evaluate their own abilities and shortcomings. It also would encourage many of the qualities of empathy, humility, and compassion - essentially embodying the Art of Medicine – which, before now, have nowhere been included in the core competencies of physicians, despite it being the unwritten expectation for all of us to develop these skills.

Many of these ideas of physician as teacher have been inspired by Dr. Ho Ping Kong, who is arguably the best teacher of medicine I have encountered in my four years of medical school. When I think of the kind of physician I would like to be in future, I think first of teaching; when I think of teaching in future, I will inevitably think of Dr HPK. Certainly he embodies the skills and strengths described by the original CanMeds roles: he advocates tirelessly for his patients, is an excellent communicator, and continues to advance his medical knowledge despite having been in practice for close to fifty years. But there is a quality to Dr HPK that is unique and goes beyond all of these traits to work a sort of magic, and that is his teaching ability, visible not only to patients but to his countless students over the years.

And so, I feel that at the beginning of this selective I was a medical student, but I have come out the other side a Doctor. A doctor who is ready to begin residency training in pediatrics, buoyed by the support and training of many physicians over the last four years, but truly shaped by individual teachers who have modeled for me the art of medicine and instilled in me qualities beyond the CanMeds competencies. I have always wanted to be a teacher, but this past month crystallized for me what being a teacher truly means. It has inspired me to seek out more opportunities for practicing my own budding teaching skills, to continue to develop a critical consciousness, and to embrace self-reflection and self-awareness. Though they are incredibly large shoes to fill, I hope to become a teacher of medicine, a doctor, like Dr. Ho Ping Kong; and a mentor to other students as he has become for me.

~LG

A Final Reflection

When I signed up for this selective, I envisioned a rotation that mainly consisted of ambulatory clinics and rounds. In terms of the medical education piece, I had initially thought that we would receive seminars on how to teach. I was not aware of the huge amount of formal literature that existed on the topic. In retrospect, I am glad we were given the freedom to pursue our own educational interests. In referencing my previous posts, it allowed me to study something that I found important and thus provided me an intrinsic motivator to learn. At the same time, it was also nice that we were provided the time to do our literature searches without pressure. I am very happy that I was able to tie my research in directly with my final presentation.

As I mentioned in my first blog, I have always liked teaching. In fact, it was one of my first career interests before I discovered my passion for science and I kept it up ever since through tutoring and mentoring programs. However, spending clinics with Dr. HPK has shown me that teaching well isn’t just about content. Like the physician-patient relationship, it encompasses the entirety of the encounter. It’s about connecting with your student on a personal level and understanding their strengths and weaknesses, their learning style and tailoring the teaching to the individual. It’s about the delivery and providing a comfortable environment to challenge them to think outside the box. It’s also about providing understanding and context as a basis for integrating their knowledge. One topic of particular emphasis was empathy. Throughout medical school we’ve always been taught to demonstrate empathy through the simple approach of adding “empathetic” sentences such as “oh that must be difficult” and “I can’t imagine how you must feel” etc. However, Dr. HPK demonstrates another, arguably even better method to convey empathy through plain, yet meaningful conversation. No matter what the age, race or social status of the patient, he always finds a topic of interest with which to bond. Travelling and business are common themes; however, I’ve also seen him build rapport with more esoteric subjects. One time, he connected with an Ecuadorian man by talking about the Galapagos Islands. By showing that we care for patients’ personal lives, we gain that trust from them that is all the more valuable during times where medical decisions must be made. I witnessed several instances where patients who would otherwise refuse treatment or challenge management put full confidence in Dr. HPK. He attributed that privilege to the years he spent chatting with the patients.

The other part of my selective was focused on research and making my presentation. As I am going to be a radiologist, I am very interested in medical education around that topic. While my initial ideas revolved around radiology curriculum development, I quickly discovered that there is very scant research surrounding implementing formal radiology curricula and the research that do exist only serve to say that there is interest regarding more exposure/teaching etc. Thus, I turned to investigate how to improve the current system and through that came across the idea of Student Response Systems (SRS). Having used both “old-generation” and “new-generation” SRSs, I could say from experience that they definitely helped engage me in the lectures where they were used. Through my research, I discovered that while SRSs definitely do benefit the teaching process, their direct and independent influence on positively improving learning is still debatable. Nevertheless, their efficiency and practicality definitely warrant further research into potential incorporation into curricula and additional research into their positive effects on learning. Having tested out the SRS Socrative in my presentation, I can say that it is easy-to-use, effective in providing feedback and generating discussion and very useful in increasing participation and promoting anonymity. I found it especially valuable in testing application following my lecture and with its imaging features, a definite asset to any radiology lecture. During this time, I was also introduced to another SRS, Poll Everywhere. I discovered one hidden gem in one of its features, especially pertaining to radiology, which is that it allows one to upload an image and select an area of interest (e.g. classic finding, pathology). Then participants are asked to click on the image on their smartphones where they think the finding lies and the responses are fed back to the system and verified to see if they match the intended area. I can foresee this being an interesting way to teach lower-level radiology students in “finding the abnormality”.

Overall, I am extremely satisfied with this selective. Not only did I have a great time, meet some great mentors and learn some great medicine (at a convenient time I might add), I also took away several skills and tools that I can definitely incorporate into my future career. While I may not have the most patient interactions in the future as a radiologist, the teaching I received on this rotation regarding mentorship and empathy will serve me well in interacting with other staff, residents, students and health care professionals. As someone who will definitely promote radiology education in the future, I also acquired some invaluable knowledge regarding how to most effectively present images to students and some ideas in how to improve our lecture series. Finally, through my research, I managed to identify some areas in curricula that lack the necessary research to justify change. This is something that I plan to work on throughout my career and hopefully result in some innovative and useful renovations to our current educational system.

-DW 

Reflection and Refraction

I have spent much of the last year or two thinking about empathy. An etymological breakdown of the word is ‘in – feeling’; from the online etymological dictionary we get the definition of ‘A term from a theory of art appreciation that maintains appreciation depends on the viewer's ability to project his personality into the viewed object.’ Similarly, empathy was once described to me as a way of ‘feeling your way in’ to a person. When we empathize with patients effectively, we are feeling our way into their state of emotional, physical, and social wellbeing. In medical school, our Art & Science of Clinical Medicine (ASCM) course intends to teach us patient-centered interviewing techniques, encouraging us to be non-judgmental, cultivate empathy, engage in active-listening, and connect with our patients. But does this truly teach us how to understand our patients? Four years later, I can see that there are clearly individuals to whom this comes more easily or those who have learned to be better at this Art than others. In my previous post, I alluded to changes in medical education that are focused more on encouraging these non-medical expert components of physician competencies, but today I would like to discuss it in more depth.

What is it that makes some of us better at connecting with our patients?
How can we learn to be better at it?
hat are some of the barriers to developing this skill?

I think at the root of this ability to empathize with our patients is awareness. This awareness is not only of others, but also of ourselves, and of how we interact with others. Medical Education has done a much better job in recent years of addressing diversity in our patients, not only in terms of race and gender, but also varied cultural groups, sexual orientation, and socio-economic status. This intrinsic curriculum does a good job of increasing knowledge of others (often described as Cultural Competency) but often falls short of true understanding, and, it does little to address knowledge of our self, our personal prejudices, biases, and privilege that influence how we interact with the world.

Beyond Cultural Competence: Critical Consciousness, Social Justice, and Multicultural Education, by Kumagi & Lypson, addresses this particular issue very succinctly. They comment on the very nature of the term ‘Cultural Competency’ as a “knowledge of characteristics, cultural beliefs, and practices of different non-majority groups, and skills and attitudes of empathy and compassion in interviewing and communicating with non-majority groups”; as such it is often thought of as a static outcome, as opposed to a way of being. They argue that it is far more important to cultivate a Critical Consciousness: “the continuous critical refinement and fostering of a type of thinking and knowing of self, others, and the world.”

This idea, whose conceptual roots were developed by Paulo Freire, requires a deep awareness, not only of others, but of ones’ self and the disparities and differences that exist subsequent to power and privilege imbalances; Friere describes this as “reading the world”. Further however, it involves reflection on our own emotional and intellectual response to knowledge of this inequity. By employing self-reflection, we can increase self-awareness of our own implicit biases, beliefs, and values that may affect how we respond to others that may be similar or ‘other’ to ourselves. By understanding and being able to predict our responses, we can therefore adjust our interactions on an individual basis to best empathize and connect in a therapeutic manner.

If developing critical consciousness it the goal, I would argue that current strategies in place at this medical school at least are not adequate. There are individuals certainly that have learned to be self-aware independent of being explicitly taught, but should we not encourage all medical graduates to achieve this ability? The challenge however, is determining how this ability can even be taught or incorporated in medical education curricula.

Enhancing Self-Awareness in Medical Students: An Overview of Teaching Approaches by Benbassat & Baumal provides an excellent review of several studies published at a variety of medical schools that have attempted to address this in their curriculum. Of note, Henderson & Johnson discuss a course in Cambridge that has been developed that consists of 16 full or half-day workshops where small groups meet to have an encounter that is designed to foster self-reflection and personal development and then must subsequently write a reflective evaluation of the session via e-mail to their preceptor. While many of these studies are very interesting, Benbassat & Baumal highlight the lack of depth and controlled studies in this field, cite many of the challenges or potential pitfalls of these approaches, and conclude that: “before we recommend the use of direct small-group programs for enhancing self-awareness, medical educators must be more certain than they are today that the benefit of such programs exceeds their cost.”

At our own school, we have the Portfolio course which has us meet in facilitated small groups to discuss and reflect on experiences we have had throughout clerkship and to subsequently submit a written reflection. While I have found this course valuable as an opportunity to see friends and discuss challenging experiences, I have often found it limiting as it requires you to select and write about stories centered each time on a particular CanMEDs role. The reflections I have created were useful when it came time for my CaRMS interviews, but in retrospect, I think there is the potential for so much more in these small groups.

Imagine the opportunity for discussing specific lived experiences: As an example, we have the chance in second year to practice a palliative care end-of-life discussion in an ASCM group. While useful practice, there is so much more that could be gleaned from that discussion beyond the practical skills. A portfolio group meeting immediately after a workshop surrounding end of life care could allow individuals to explore their feelings surrounding death, what it brings up in terms of their own emotional responses, what they believe, their own particular religious beliefs and how that might affect how they respond to other individuals’ beliefs prior to death… the list goes on. I regret not having had that opportunity to explore my feelings and emotions with my colleagues in situations such as these and to have helped others to develop to become better physicians.

Noon rounds today were particularly inspirational, focusing on the art of Narrative Medicine. I was reminded again of Dr HPK and the story I told in my previous post about how being there to listen to patients’ stories and bear witness can be equally as or more effective than a physical treatment. Dr Abdullah used the term ‘refractive listening’ in describing one of her narrative exercises. It particularly captured the idea that a story is changed by being told and by being heard. By listening and absorbing and responding to the story, not only are we reflecting it back towards others but we are in fact refracting the story, or changing it into something more, and giving it deeper meaning.

As physicians we are incredibly privileged to encounter so many individuals in our lives with amazing stories, just waiting to be told, heard, and given deeper meaning. We all know how to listen, but for a patient to be truly heard and for us to feel fulfilled, we must cultivate our empathy, our self-awareness, and a deeply critical consciousness. We are truly doing our future patients a disservice by not incorporating formal teaching in these areas to our current standards of medical education.

~LG