Educating Educators

We need to see in today's medical students and residents not only the future of medical practice, but the future of medical education. They are the medical educators of tomorrow. Yet faced with the daunting challenge of teaching medical students and residents everything they will need to know to be good physicians, we frequently forget to see them as educators. We treat them as passive recipients of education rather than future educators in their own right. This approach is grounded in part in a mistaken view that we must first become experts in a subject before we can begin teaching it. How could a medical student or resident who has been studying a subject for only a few years presume to teach it? How could they possible compare to a faculty member who has been at it for decades?

Yet teaching is not a prerogative that we acquire only at the end of a long course of training. Instead, teaching is an art in which we should begin to gain firsthand experience almost as soon as we embark on our education. We expect medical students and residents to begin taking histories, examining patients, and performing procedures before they have acquired full proficiency, because they cannot learn otherwise. Similarly, we need to expect them to start teaching even before they know everything, because otherwise they will not lay the groundwork they need to excel as educators.

We are kidding ourselves if we think that students and residents do not need to teach. For one thing, all of them interact from time to time with more junior colleagues. The freshmen learn from the sophomores, the sophomores from the juniors, and the juniors from the seniors. Likewise, the seniors learn from the interns, the interns from the residents, and the junior residents from the senior residents. Patient care is an inherently educational activity,because medical students and residents are continually called upon to explain things to patients, and to educate patients about their problems and their care. Why, then, do we not recognize such educational opportunities and do a better job of preparing learners to meet them? We spend countless hours teaching medical students about molecular biology, anatomy, physiology, pathology, how to take a history and perform a physical examination, how to perform procedures, how to find information, and so on, but little or no time helping them learn how to be more effective educators. By spending so little time on it, we send the implicit message that it is either not very important or there is very little we can do about it. Perhaps we believe that we really cannot teach teaching, because we ourselves know so little about it.

If we understand better why it is important to prepare our learners to excel as educators, we will also illuminate what we need to do and how to go about doing it. When we gain a better grasp of the need to place greater emphasis on teaching, we also illuminate the format and content that such educational learning should take.

For one thing, education is an essential part of the covenant of medicine. To practice medicine is a privilege, both in the sense that society allows physicians to do things others cannot, such as prescribe medicines and perform surgeries, and also because those who enter it are entrusted with a rich legacy of knowledge and skills that were acquired through the blood, sweat, and tears of many great physicians and scientists over many centuries. When we enter the profession, we take an oath, often a modified version of the Hippocratic Oath. That oath enumerates many responsibilities of a physician, both positive (pursue the good of the patient) and negative (do not betray the patient's confidence). But the responsibility the Hippocratic Oath places first is the solemn responsibility to teach the art of medicine to those who follow us. The primacy of this obligation bespeaks the wisdom of the first Hippocratic aphorism,"The art is long, life short."

The art of medicine is far longer lived than any of us. It was here long before we came on the scene and it will persist long after we are gone. We are fortunate to be admitted to its fraternity, and we owe it to those who taught us, and those who taught them, to pass it along in as fine a form as we can to our students, and to prepare them to do so for theirs. The art of medicine is less like a stone tablet than a torch, and if one generation drops it or allows its light to be extinguished, it would take many generations to restore it. The better we prepare those to whom we pass the torch to pass it in their turn, the better for medicine and the patients it serves.

Education is also built into the very essence of what it means to be a doctor. The word doctor is derived from the Latin word for teacher. The verb is docere, which means to teach. Hence to be a doctor is to be a teacher. Before we can teach, we must learn, but it is in large part teaching that we should aim to learn, and to pass on to our learners. We cannot excel as physicians unless we teach well, and this is the spirit in which we should prepare our learners to be educators.

Great harm can be done by the misconception that we must be members of medical school faculties to be teachers. In fact, as we have seen, every physician is a teacher. Most of the teaching most physicians do takes place outside the classroom or teaching rounds, when we teach our patients and their families. Our efficacy as physicians is not only defined by what we know. It is also defined by what we are able to get across to others, and in particular our patients.

We must also educate other health professionals, including nurse, social workers, respiratory and physical therapists, dieticians, and even chaplains. Do we do a good job helping them to understand our patients'situations,the nature of the assistance we are hoping they can provide, or where we worry we may have missed the mark? Being a good educator in this context means not only telling others what we do know, but also letting them in on what we don't know, and how they might help us. If our learners do not understand how to share knowledge in such contexts, they will be less effective physicians, and their patients will suffer.

In terms of professional flourishing, mere knowledge and skills are not enough. The physician who knows the most does not always make the greatest contributions, and the same can be said for the most skilled individual. Performing well also requires that we organize our thoughts effectively, focus on the most important points, and sustain the interest of our audience. These are traits of a good educator, and they are also traits of a good physician leader. Patients may not see our medical school grades or our scores on standardized tests. They may not know our final class rank when we graduated from medical school, or whether we were chosen to serve as chief resident. They do, however, notice how effectively we speak and write, and these are abilities that we dare not take for granted in our educational programs, lest they atrophy from lack of attention.

It is a mistake to suppose that educators are born and not made. To be sure, some people are more gifted than others, and others seem to face some constitutional hurdles in learning to teach effectively. Many anxious students and residents would prefer never to be called upon to speak in public. Of course, many might also prefer never to examine a patient or insert a central venous catheter, but we recognize that such skills are essential to medical practice.

Our educational programs should, as far as possible, prepare people to excel as physicians, disregarding what is easy for the sake of the necessary. Many learners report that it was the things they felt most anxious about that turned out to be the most rewarding aspects of their educational experiences, in part because they frequently permit the most growth and development. Teaching involves a number of learnable skills, and if we make a sincere effort, it is one in which virtually everyone can improve. Not only does such effort make us better teachers, its benefits spill over into other aspects of our professional and personal lives.

Becoming a good teacher means becoming a better learner. The best educators know that teaching is one of their most important learning opportunities. There is an old Yiddish saying, "He who teaches learns twice." We never learn something so thoroughly as when we teach it. People who teach something for the first time report that they never understood the subject so well. It makes us dig deeper into the subject matter, and look at it from multiple perspectives. In explaining it to others, we see it better for ourselves. This helps us to set our cognitive bar higher when we study new subjects,because we have a better sense of what it really means to understand something well.

Teaching also helps us to understand better how people learn, including ourselves. Do I learn better by hearing or seeing? Which works better for me, attempting to memorize mnemonic devices or understanding the underlying pathophysiology? Do I learn best by trial and error or by imitating some else's performance? Becoming a better teacher also helps learners become more effective consumers of teaching. They may be able to offer more constructive criticism of the educational programs they are part of, and play a greater role in improving them. Savvy learners are not threats to our programs, but key ingredients in the recipe for ongoing improvement.

The future of academic medicine, and thus of all future physicians, hinges in part on the educational abilities of the physicians we are training. Poor teachers mean poor education, which threatens the quality of research and clinical practice. We need to attract top-quality people into academic medicine, and provide them the knowledge and skills they need to succeed. Yet how can today's medical students and residents make an informed judgment about their prospects as academic physicians if they gain little or no experience with what academic physicians do? How will they know whether they like teaching, or are good at it, or would like to try to be? By providing meaningful educational opportunities to our medical students and residents, and by helping them to succeed as new teachers, we can help to secure the future of academic medicine.

Some of the colleagues I respect most report that the most satisfying aspect of their careers has been the opportunity to help educate the next generation of physicians. It is one of the most profound and enduring sources of professional fulfillment. There is something intellectually and even spiritually rewarding about helping others to excel at the craft to which you have devoted your life. If we keep our medical students and residents so busy that they never have chances to experience teaching firsthand, we are doing not only them but also our profession a profound disservice.

What should we do? First,we should include curriculum on how to teach effectively in both medical school and residency. It is simply not the case that we know nothing about what separates effective educators from ineffective educators, and that what we know cannot be put to work to help people teach more effectively. Such information could be embedded in regular course work and conferences, or it could be the subject of retreats and other special events. Such learning opportunities need not always be presented by physicians, and in fact we in medicine have a lot to learn from other disciplines, such as psychology, about the enhancement of learning. What do good teachers do, and how can we use this knowledge to help learners enhance their own effectiveness as educators?

Second, we should provide formal opportunities to teach. Teaching should be a regular part of the educational programs of medical students and residents. We should also provide opportunities for trainees to receive constructive feedback on their performance, so they can improve as educators. Medical students and residents often do a very good job, perhaps in part because they are enthusiastic, the material is fresher to them, and their level of understanding is often closer than that of the faculty to the people they are teaching. Although residents and medical students should never be exploited, such programs provide the ancillary benefit of offloading some educational responsibility from faculty, who can devote their time to activities for which they are more uniquely qualified.

Third, we need to alter the criteria by which we evaluate medical students and residents to include their performance as educators. When we accredit medical schools and residency programs, we should look for evidence that they provide meaningful educational opportunities to their learners. Our specialty societies should make available grants for educational innovations that help learners become better educators. Awards from national associations might help recognize programs that do an especially good job in this regard. Research and innovation in education should receive more attention at many national professional meetings.

When we see that education is taken more seriously, we will be more inclined to invest our time and energy in it. This can spawn a culture change in which education is more highly esteemed across the board, raising its profile and enhancing its practice. When that happens, the entire profession and the patients it serves reap the benefits.

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