Foreword by Thomas Inui

Excellence in Medical Education: Looking Beyond "See One. Do One. Teach One."

Carry Me Back

Philip Tumulty was Johns Hopkins Hospital's "doctor's doctor". White-haired, red-cheeked and vigorous, he seemed to know more medicine than almost anyone else at Hopkins and he put this knowledge to use in the care of patients. Unlike some of the other major figures at the school, he was predominantly an active clinician with a busy consultative and primary care practice. As students, we first saw Dr. Tumulty at Clinical Pathology Conferences (CPCs), where he always "wowed" us with his erudite comprehensiveness and (in the end) uncanny capacity for being correct about what disease process was at work in the case under review. I loved the moments at which Phil's discussions would finish the elaboration of an incredibly long differential diagnosis, an exhaustive list of what the mystery patient might have had, and take on a new tempo—like a horse rounding the last turn in the track—suddenly picking up speed, gathering himself, and racing for the finish line, arriving at the final diagnosis in a rush and lathered up.

The times I most enjoyed learning from Phil, however, were not in the CPC but in his end-of-afternoon "case discussions" in the Thayer classroom. These discussions usually centered on a patient Phil had in the hospital. Phil and one of his patients would sit in the front of the classroom and talk as he "took" the history, in a somewhat casual and discursive manner, and inevitably learned something more. I particularly remember his conversation with a retired judge from Virginia, who was to be discussed as a case of possible granulomatous arteritis. Probably wanting to learn more about fatigue and waning vitality, Phil asked the judge "what he liked to do." A whole world of country life in the rolling hills of Virginia opened to our sensibilities. We were going to the kennel in the autumn to let the eager dogs out—then rambling across the blue hills behind the dogs on the pretense of "hunting pheasants" but actually wanting just to breathe the air and be in the fields, shotgun unloaded, broken over the arm, strolling under the azure sky. What space; what beauty. How we loved being there

Oh yes, and we did get back to night sweats, tender spots on the scalp, and the upcoming temporal artery biopsy, but what a "trip" that was and how we knew this case.

One of the most astonishing characteristics of physicians in academic medicine is the extent to which they seem incapable, outside their endeavors in research, to think systemically, historically, and theoretically. One of this special variety of homo sapiens academii myself, I recognize our lack of systems thinking when it comes to imagining how to minimize patient risk, improve quality and efficiency of care, and reengineer processes of care to enhance integration services. Having shifted my academic organizational base three times in my career, I have been surprised by how little most of my colleagues in academic medical centers know about major eras in the history of medicine, the modern history of American medicine, the history of their own organizations, or how, when, and why—from a social and cultural perspective—the systems we work in today materialized in their present form. To complete this brief lament, I am repeatedly surprised by how atheoretic we are in much of our work, locked into conventional practices, and not naturally inclined to wonder how our work processes, ranging from patient counseling to organizational management, might play out differently if we used theoretical perspectives to shape our actions or to envision the full range of our choices.

In no domain is this lack of "mindedness" more apparent than in education, the quintessential activity of academic medicine. The old saw describing how one prepares to teach in medicine is telling: "See One. Do One. Teach One." The origins of this aphorism must be in the "apprenticeship" era of medical education. The apprentice could see his or her master carry out a procedure, try it him- or herself (it is hoped with feedback from the master), and then teach others in turn how to successfully accomplish this task. Even relatively complex procedures are still learned in this way: spinal taps (lumbar punctures), paracenteses for draining fluid from the free space in the abdomen, thoracenteses for draining fluid from the intrapleural space in the chest, and so on. In the case of some other specific procedures, such as sigmoidoscopy, training programs have specified the number of times a trainee should practice the procedure under supervision before performing it independently. Fifteen sigmoido-scopies, for example, are thought necessary before a trainee is capable of carrying out this procedure independently. This changes the learning recipe to "See one. Do fifteen. Teach one," not much of a conceptual advance. This approach to education, learning by repetition and rote, seems more appropriate for the education of homo habilis than homo sapiens.

Against the backdrop of this anhistoric, atheoretic, and learning by rote environment, Richard Gunderman's remarkable volume Achieving Excellence in Medical Education is truly a learned treatise on medical education, educational evaluation, academic medical center leadership, and organizational development for excellence. Gunderman's liberal education, foundations in history and philosophy, and commitment to deliberating a deeper understanding of the principles and practice of organizational and educational management is clearly evident. He writes from a basis of personal expe rience and immersion in academic medical centers, but his "gaze" is focused through the lens of educational theory, organizational management theory, historiography, behavior change theory, and adult learning principles. There are sections of importance in this volume for all "citizens" of academic medical centers, including students, residents, course directors, professional educators, academic program chiefs, and deans. I especially appreciate Dr. Gunderman's systemic thinking about the ecology of academe, how its complexity needs to be appreciated from the multiple perspectives of different participants in the "academic village," and his recognition of the importance of reflection and self-knowledge on the part of all participants. All learning, whether the acquisition of practical wisdom or theory, begins with knowledge of self, especially in dynamic and complex circumstances.

If I were to wish for one voice to be heard more prominently in this volume and, indeed, by educators in general, it would be the voice of the patient. Medical education devoid of the life world of the patient is unanchored in the ecology of health, function, and well-being of the people we serve. Knowledge and reflection that focus solely on the "medical" side of the doctor-patient relationship is, therefore, an abstraction of the tasks of medicine, rather than a living, breathing, immersion in the patient-doctor shared work in which we seek to join patients as partners, guides, companions, advisors, and healing presences. I introduced this foreword with the story of my Hopkins teacher Philip Tumulty, for just this reason.

Tumulty thoroughly understood his stance within the Johns Hopkins. He was neither a pinnacle scientist nor an administrative leader. Instead, he was a highly skilled clinician who attracted and mentored students, residents, and junior faculty by the capacity he demonstrated to join deeply with his patients. He was charismatic not only because he could think through complex medical problems with great facility (the CPC) but also because he could bring this force of mind and heart fully to bear on his work with patients,work that he chose to conduct quite explicitly within the framework of their life worlds. All educators would do well to seek, refine, and embody this capacity. It returns medicine to its historical roots as a culturally important healing activity and allows physician-educators to reclaim their legacy as those who bear and pass the torch of healing practices.

Thomas S. Inui, ScM, MD President and CEO, Regenstrief Institute Sam Regenstrief Professor of Health Services Research, Associated Dean for Health Care Research, and Professor of Medicine Indiana University School of Medicine

0 0

Post a comment