Blog | Friday, July 14, 2017

The goal of medical education #meded

I started medical school in 1971 (yes 46 years ago). I hated the first two years, but loved the third and fourth years and loved my residency.

My first month as a ward attending in Internal Medicine was January 1980. I probably have averaged over 100 days of teaching attending for the past 37 years.

What do our learners need? They need (and almost always want) to become excellent physicians. They want us to help them grow as clinicians.

Internal medicine is a very intellectually challenging specialty. We cover multiple organ dysfunctions. We learn more each year about how to best diagnosis and treat patients.

Our learners need help to progress, yet too often we see attending physicians focus on the learners' deficiencies rather than on a strategy for helping them grow.

I believe our job is to diagnosis their level of understanding and help them advance. We should work on multiple dimensions: bedside manner, breaking bad news, encouraging behavior change, taking a good history, doing an accurate physical examination, interpreting laboratory tests, evaluating imaging studies and putting the story together to make correct diagnoses. Then we need to help them make good therapeutic decisions.

We cannot expect our third year students to naturally adapt to all these issues. We must help them build a foundation for continuing growth. Similarly, our interns need encouragement to work on these dimensions. Most third year residents are very good, and we have to work hard to figure out how to help them grow further.

The best clinician educators are always striving to improve on these dimensions. We work on ways to help our learners understand important clinical issues.

Last week at morning report I started a discussion concerning the development of hyperkalemia in diabetic patients with CKD (usually 3b and above) after starting an ACE inhibitor or an ARB. The clinical dilemma of having patient who needs one of these drugs (usually for proteinuria or systolic dysfunction) and who develops hyperkalemia once the drug is started.

The purpose of starting this discussion was to introduce the new drug patiromer (trade name Valtessa).

I explained the problem brilliantly. At least I thought I had explained it brilliantly. Fortunately a third year student reminded me that I had skipped to many steps (the Curse of Knowledge). Once she pointed out that the Emperor had no Clothes (and several colleagues and interns agreed) I had to start over.

The second time through I was more careful about explaining each step in the logic.

The problem was not the learners. Our job is to help them understand. Our job is not to pontificate, but rather figure out how to explain the hows and whys of our profession.

While we have to give negative feedback occasionally, we should not be too quick to label our learners inadequate. I have seen too many students or interns get labeled. Our job is not to label but rather to help them progress. Sometimes they cannot make it, but I would argue that some students and interns struggle because we have not spent the energy figuring out how to help them.

So the goal is straightforward. Take our learners and help them progress. This requires our hard work, and that work is very worthwhile.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.