Five Patients
Page 17This Socratic tradition of teaching medical students dates back to the days when medicine was an apprenticeship in the strictest sense. The Socratic method has the virtue of informality: on work rounds, the resident can ask the student in passing, "How will we know when Mr. Jones is adequately digitalized?" and the surgeon can pause in his operation to ask the student, "What would happen if I cut this nerve here?" It is a good way to keep the student constantly recirculating his knowledge through his brain, and by and large it works well.
Why not just state the fact, as a declarative statement, for the edification of the student? There is just one major reason: most medical students are tired. At any given moment, a lecture to a medical student is a signal to click off, to tune out, to go to sleep. Partly, this is a learned response. It is common, during the first two years of medical school, to have four hours of lectures and five hours of laboratory work in a single day. Students who are studying late into the night on top of this schedule learn to sleep during lectures with great facility. The pattern carries on into the clinical years. One can observe lectures to medical students and house staff in the hospital in which 20 to 50 per cent of the class is slumped over in their chairs. The lecturer pays no attention. To a lecturer, it is not an insult, but a fact of life. Everybody accepts it; everybody expects it.
The only way to beat the dozing off is to ask questions. Supposedly this makes the learning experience more active, less passive. But, as anyone who has ever attempted to put together a programmed text knows, teaching by questions is extraordinarily difficult. The ideal set of questions is graded, going from fact to fact, leading the student from information he knows well to the reasoning out of information he does not know. On the other hand, the usual unplanned set of questions just draws a blank look and a guess.
For some reason, the question-and-answer teaching method is a peculiarity of professional school instruction. It is common in law, medicine, and business, and practically unknown in other graduate fields. The best teachers can employ it to great effect; most teachers are hopeless at it.
The system is most likely to succeed when applied to an individual-and almost certain to fail when applied to large groups. I have watched a specialist in diabetes walk into a room full of third-year students, rub his hands together, and say: "All right. Let's suppose you've gotten your diabetic patient. He has a blood sugar of three hundred. What kind of diet are you going to put him on?" Nobody in the room had the faintest idea what kind of diet to put him on. "How many grams of carbohydrate do you want to give him?" the instructor demanded. Nobody knew; nobody said anything. Finally he pointed to a student and insisted on a figure. "Ninety grams?" the student said. "Wrong!" said the instructor, and went around the room until somebody finally guessed one hundred grams, the figure he wanted to hear. "Now then, how much insulin do you want to start him with?" the instructor asked, and the game began again.
It would be pleasant to think such examples atypical of medical education, but in fact they are more the rule than the exception. Considerable dedication is required of students to learn medicine in the face of such teaching; one often has the impression that medical education works despite itself.
Useful changes can be made in all elements of the process^-changes in the students, changes in the teachers, changes in the teaching methodology. Of these, only one appears very likely: the traditional routine of every-other-night for clinical students and house officers is dying. Many hospitals are shifting to an every-third-night schedule, which makes a considerable difference. The student or house officer sleeps through his first night off, but he is able to read during the second night; and during the day he is more alert, more awake. This helps to remove one of the oldest paradoxes in medical education-namely that the hospital claims to provide an excellent learning environment, while systematically depriving its students of sleep.
A change in teachers is less likely. Clinical teaching posts have status attached to them; a private man likes to be able to say he "spends some time with the students." At the same time, teaching hasn't got much value as a way to be promoted within the academic hierarchy; medicine, like every other field, puts its emphasis on published research. This leads to a multitude of rather casual teachers who may spend only a few hours a year with the students. These people-like the diabetes expert, who comes to the hospital once every three months to deliver his little talk-are most pernicious. They do not care enough about teaching to attempt to do it well; they don't have enough experience with students to know how to direct their talk; they have never received any training in exposition and attach no significance to a good delivery.
Having dismissed these people, one should say that medicine does indeed correctly sense that private, experienced practitioners have accumulated practical knowledge that ought to be communicated to students. Unfortunately, this is not the way to do it.
The methodology continues to be perplexing. The notion that the subject should be suited to the manner of teaching; the idea that certain things are best taught in lectures, others in seminars, others individually; the understanding of those qualities that distinguish the lecture from the slide from the
printed page from the visceral experience-all these things are traditionally lacking in medicine.
Future medical educators, for example, will probably look back on the teaching hospital and shake their heads at the way "patient material" was used. One can argue that this use, at the present time, is highly inefficient. The individual patient in a teaching hospital is not intensively used for teaching. A bizarre case may be seen by fifty or sixty people, but the average ward patient is seen by many fewer, particularly if his problem is common and his stay in the hospital is short.
The need to see patients firsthand is an important part of medical education; one must have experience with many ill individuals, exhibiting many different manifestations of disease. This is necessary because there are both many diseases, and many forms that a disease will take in different people. To obtain the proper depth and breadth of experience requires a long time; a student or house officer must remain in the hospital at all hours for many years. Otherwise, he is going to miss vital experiences.
However, a number of ways of "saving the patient for future reference" are now possible. Teaching collections of X rays have existed for several years, enabling students to gain broad radiological experience without waiting for the patients actually to come in. But this is only the beginning: one can record a patient's appearance and important physical findings on video tape; one can even record an interview and history-taking. By such techniques literally hundreds of students can, over a period of years, have some experience with a given p;
And one can go further. For example, one n most severe limitations of modern clinical tea is that the student cannot really use the pati""practice on." While mistakes are an imp* part in any learning process, in the hospita are discouraged and guarded against-and n so.
What is needed, of course, is a disposable tient, for whom mistakes do not matter. In the one can argue, the disposable patient was pro by society in the form of the charity case (at this was the popular belief); but this requiu can now be provided by technology. Anesti have developed a lifelike plastic dummy i for students to practice on; this dummy can allergic reactions to anesthesia, cardiac and n atory arrests, and a variety of other serious ci cations. The student can practice on the di"with impunity. So far, the only analogous sin is that provided by the post-mortem patient used for practice of surgical procedure. B" will see much more in the future.
For example, a teaching program can be pii a computer, enabling the student to ask ttu tient" questions, and get back replies. On th-. of such an interview, the student can make a nosis and institute therapy. The computer car inform the student of the consequences of hi scribed regimen.
nt selects the therapy he wants and er- acked-out space to reveal the conse- his choice. If he has chosen correctly, i will be encouraging: "Patient im- Hut if he is wrong, the answer is likely to Patient dies."
se techniques, it is possible to give the posure to rare clinical situations he r see otherwise. It is also possible to ulent exposure in depth to a problem. iiki program the differing clinical histories patients with hyperthyroidism, for ex-let the student work through them all, idea of the differences from case to nt this will ever replace experience at the it it will certainly supplement that and very soon. There are two reasons L-chniques will gain rapid acceptance.
is a slowly simmering rebellion against the length of medical education. In this country the average physician is almost halfway to the grave before he is prepared to start practice-and the trend is toward even longer educational periods, not shorter ones. At the same time, there is a demand for more physicians, and the suggestion that this demand can be met, in part, by faster education. There is also a growing suspicion that in affluent America some of the best young men shun medicine because the educational period is so long.
As an educational process, medicine has suffered the full effects of the scientific outpouring of information; the response of medical educators has been simplistic-to lengthen the period of formal training as the body of knowledge has increased. This cannot go on indefinitely, and specialization-breaking up knowledge into smaller and smaller areas-will not provide the whole solution.
As a stopgap measure, medical schools have kept the total number of years constant, but have lengthened the per-week teaching load. Thus medical students at Harvard attend twice as many hours of classes per week as law or business students. Of necessity, this makes medical education a very passive business and deprives the student of the single most important thing he desperately needs to learn while at school-how to initiate the educational process for himself, later on, when he is a practitioner.
For medical schools there are only two solutions: to teach less or to teach more efficiently.
Medicine has been reluctant-sometimes wisely, sometimes not-to teach less. Curriculum changes are a traditional sport, but they occur slowly (John Foster notes that "it is easier to move a graveyard than to change a medical curriculum") and never seem to make manageable the total information to be mastered. The current administrative structure of medical schools appears incapable of curtailing the curriculum. Educators must therefore devise ways to teach faster. It is the only solution.
If it is hard to be a student, it is much harder to be a good visit, for a visiting physician has the most difficult teaching job in the world. His "class" of students, interns, and residents is small, but their depth of knowledge is dissimilar, and the visit must endeavor to teach everyone. His subject matter is all of medical knowledge; he must act simultaneously as adviser, librarian, lecturer, and, at the bedside, as a direct example in dealing with patients. The best visit is a marvel to watch. In an hour he can listen to the student, quiz him, arrive at a diagnosis, proceed to deliver a ten-minute extemporaneous lecture on some aspect of the diagnosis, throw in one or two humorous anecdotes, see the patient and elicit more information than the students and house staff were able to obtain, in the process demonstrate an obscure physical sign, then step into the hall and summarize the entire situation in a few minutes.
The whole act depends on vast knowledge, clear organization, boundless energy. But it is also the final check in the long system of built-in checks- the intern checks on the student, the resident checks on the intern, and the visit checks on everybody.
What does all this mean for the patient? Most teaching hospital physicians believe it produces better patient care. According to Dr. Robert Ebert, dean of Harvard Medical School, "It is far easier to check on the mistakes of an incompetent intern than the mistakes of an incompetent private physician. It is one of the ironies of our system of medicine that a very sick charity patient in the ward is likely to receive better and more constant medical attention than his counterpart on the private side of the hospital."
These considerations lead Dr. Ebert to talk of "the privileges of being used for teaching." This is an idea foreign to most private patients, yet our definition of the "teaching patient" is in the midst of drastic revision for that most fundamental of reasons, money. The financial structure of the hospital is changing, and with it, everything else.
Originally, the Massachusetts General and hospitals like it were founded to care for the sick poor. Patients entering the hospital agreed to be used for teaching, in exchange for medical care they could obtain no other way. At this time, there were virtually no private patients in the hospital. Any individual of means preferred to be treated- and to be operated on, if necessary-in his own home. Even at the turn of the century, the hospital was no place for the wealthy. When the Peter Bent Brigham Hospital was built in Boston in 1913, its planners made no provision for private patients.
Soon thereafter things began to change. The development of anesthesia made operations more common, and the use of Listerian antisepsis did much to reduce cross-infection and epidemics of "hospitalism." The hospital emerged as a place for all severely ill patients, private or charity cases alike. In 1917, the MGH built a pavilion entirely for private patients, and in 1930, another. By 1935, 40 per cent of hospital beds were occupied by paying patients. By 1955, it was nearly 50 per cent. In 1967, some 60 per cent of patients admitted to the hospital went to private pavilions.