Some skills in medicine are harder to teach

Teaching facts is easy. Medical students eat facts like Cheetos, and regurgitate them like…well, use your imagination. Ask them the details of the Krebs cycle, they deliver. Ask them the attachments of the extensor pollicis brevis, and they’re likely to describe the entire hand to you. Facts, and the learning of them, has traditionally been the focus of the first two years of medical school. The second two years deals with putting facts into action. Teaching medical students and residents is very different from being a school teacher, something with which I have first-hand knowledge and experience. Fetal doctors want to learn…they’re too scared not to. In general, give a med student a book, and she’ll read three, and write a paper before you see her again. But some things in medicine are harder to teach.

Medical education in America underwent a revolution at the beginning of the 20th century, when texts were written, schools formed, and methods standardized. Now, 20 some-odd years into the evidence-based medicine revolution, medical education is improving once again.

MarkH describes a method being tested to teach doctors to think under pressure. The big difference between this and the way these things have traditionally been done is that people are measuring them. They are forming hypotheses about learning and testing them. And it’s about damned time.

My current teaching responsibilities are primarily those of teaching nascent internists how to practice their profession. The facts are (usually) there, but the judgment is not. This is also a field ready for evidence-based evaluation, but some things really do require repetition and mentoring.

I supervise residents at an outpatient clinic. They see their own patients, and they see patients who either walk in or make appointments for immediate problems. Treating patients you know is one thing—treating a complete stranger is another.

Certain simple-sounding judgments are very difficult to teach and to make. For example, as a practicing physician you have to be able to answer the questions, “is this patient in front of me right now acutely ill? Does he look sick?” It sounds simple, but it’s not. Sure, there are various measurements that help make the decision: blood pressure, heart rate, temperature. But ultimately you form a gestalt and act on it. If you send every patient to the emergency room, you’ve made a mistake that will not only get you ridiculed by your peers, but will not help patients. But sending a patient home with subtle evidence of a serious disease…

Recently I saw a patient with one of my residents. She had a swollen leg—for six months. What made her come out on a snowy night to finally get it checked isn’t clear—but it is a clue. After a very thorough evaluation by a very good resident physician, he felt we should send her home for further outpatient work-up. I usually let my residents make their own decisions and their own mistakes, otherwise they will never come to depend on their own skills. But if I feel it’s necessary, I override their decisions. This was one of those cases.

Outpatient medicine requires a tolerance of uncertainty—the patient isn’t in the hospital where you can confirm every hunch with a test. You have to decide how to approach the person now, with an incomplete database.

A single swollen leg can mean many things. If it is of recent onset, the most urgent thought is usually a blood clot. Studies have shown that these are difficult to diagnose clinically, and that delay of treatment leads to increased morbidity and mortality. A chronically swollen leg is a little different. But it could still be a clot. What if underlying lymphedema led to a new clot? What if it hasn’t really been swollen that long? What if the thing that brought the patient in on this particular night was something they couldn’t identify, but they just felt subtly different? I sent this one to the ER for an ultrasound. Whether I was right or not is irrelevant to the decision-making process.

Another resident of mine was seeing a somewhat difficult patient, “difficult” meaning she doesn’t really follow medical advice, takes poor care of herself, and gives the doctor a feeling of futility. He presented the facts of the case to me, her history, vitals, physical exam. I thought about it for a minute as asked, “Does the patient like you?”

Blank stare.

“Does she like you? Do you feel you made a personal connection?”

Forming a relationship with a patient is something not easy to teach, but the importance of it can be taught quickly. If the patient likes you, they are apt to try to please you by following at least some of your advice. It may take months or years, but if a patient likes you, you can accomplish things where others have failed.

Finally, there is distinguishing what is important from what is not. This is a fear that most medical students recognize very well, and that will haunt your dreams as an intern. The most trivial fact can be important, and the most dramatic physical finding can be of little significance. There is an experience factor here, especially because sometimes there is no right answer.

A patient came in recently with a bad cold. The resident did a great job making sure nothing more serious was going on, like strep throat, and, by not prescribing an antibiotic, avoided the sin of pleasing the patient at the expense of good practice. But as he did the paperwork, he sat there obsessing about how many days off work to give him.

Unfortunately, I went into curmudgeon mode and said, “One day, three, it doesn’t matter. It’s ten at night, so make a decision and live with it!” Not a great teaching technique.

Teaching and practicing medicine is an awesome responsibility, and great fun. Hopefully, research will continue to improve the way we do it. But nothing will substitute for seeing patient after patient, day after day.