This month and next, almost 20,000 U.S. students will be reporting for their first day of medical school. Guiding them through this process are almost 150,00 faculty members, many holding MD or PhD degrees, often boasting decades of experience in patient care, research, and teaching. At this time it's worth remembering, though, that our most important medical educators never went to medical or nursing school.
They are patients, the people for whom medical students are learning to care. As the great medical educator William Osler once said, medical education at its best “begins with the patient, continues with the patient, and ends with the patient.” In other words, no matter how knowledgeable and skilled our medical school faculty members, medical education centers less on what the teachers seek to teach than on what patients need future physicians to learn. As in warfare no battle plan ever survives initial contact with the enemy, so in medical education no educational blueprint supersedes contact with the patient.
Tyler was a top-notch third-year medical student, beginning his first clinical rotation. At his orientation session, he was told that he would be assigned patients to see and work up prior to his attending physician. He would interview them, examine them, look up their test results, write a note in their chart, and then present them to the attending physician, making recommendations for further diagnostic evaluation and treatment. Once he actually arrived at the hospital, however, he found things to be quite different. No one assigned him patients. His attending physicians were usually too busy to review his notes and listen to his presentations. In almost every case, the diagnosis was already known and the treatment plan had already been formulated before he arrived on the scene.
In terms of meeting his medical school’s stated curricular objectives, Tyler’s medical education was leaving a lot to be desired. But as Osler would hasten to point out, this would not prevent Tyler from learning essential lessons about what it means to be a physician and how take good care of patients. Though in many cases he would lack important knowledge and skills necessary to provide his patients with the best medical care, he could become a physician by being a physician.
Sylvia Martin was a woman in her 60s, suffering from metastatic breast cancer. She had undergone resection of her tumor, and required multiple reconstructive surgeries. She had a long history of smoking and drinking, carried the hepatitis C virus, and was now suffering from a severe wound infection that had spread across her chest and down her arm. She was readmitted to the hospital on a Saturday, the same day Tyler first met her. When he first saw her he thought, “This is the sickest patient I have ever seen.” Her family warned him that she could not be relied on to comply with medical advice, and they feared that she was reaching the end. Tyler talked with them, performed a complete patient assessment, wrote his notes, and recommended that she be transferred to the intensive care unit.
Instead her attending physician talked with the family and entered into Mrs. Martin’s chart a Do Not Resuscitate order. This meant that if her heart stopped beating, the medical team would not use chest compressions and other aggressive methods to attempt to restore it. Her cancer had spread far, she was suffering from a severe infection, and she was already on a ventilator. It seemed pointless to press hard to prolong her life further. Instead the team would focus primarily on keeping her comfortable. Both the patient and family seemed at peace with this decision, and Tyler went home for the remainder of the weekend, having Sunday off. When he came in on Monday morning, the situation had changed dramatically.
The whole family was gathered in Mrs. Martin’s room. She was unconscious. When Tyler examined her, her severe swelling made her pulse difficult to feel, and her heart sounds were obscured by the ventilator. The family asked him whether she was already gone. Tyler said that he did not know for sure, but it looked as though she was dying. He said he would come back later.
When he got back from rounds, the family was at lunch. Mrs. Martin felt cold, and despite multiple attempts, he could not feel a pulse or hear heart sounds. He started to go out to get one of her nurses, but then came back to check for brainstem reflexes, such as reaction of the pupils to light. Nothing. Then he went to get the nurse. When she came into the room, she said, “Well, shoot,” and began unhooking everything.
Tyler knew the importance of noting time of death, so he glanced up at the clock. Then he paged the attending physician, who was in a meeting. As the nurses tended to their work, Tyler stepped out into the hall to make a note in the chart. Then he saw Mrs. Martin’s family walking toward him. As her daughter approached, she asked timidly, “Is she. . .?” Tyler nodded, then sat down with the family to answer their questions. He did not know all the answers, but he was able to listen to them patiently, to hold their hands, to remain with them even when they broke down in tears, and to provide them the time and compassion they needed. For the first time in his life, he felt like a real physician, experiencing the greatest sense of responsibility and trust he had ever known.
As a medical school rotation, this experience was one of the weakest of Tyler’s educational career. It was the only clinical rotation on which he did not earn a grade of Honors, due in no small part to the fact that he did not have much of an opportunity to show his evaluators what he could do. Yet he was becoming a physician in a new and important way. No longer was he going through the motions to earn a grade. No longer was he memorizing information for a multiple choice test or demonstrating skills on a standardized patient. No longer was he playing the role of a physician in order to satisfy a teacher. Instead he was taking responsibility for the care of a real human being, and for a life-or-death decision. Although he still had a lot to learn, he had become a physician.
There are important lessons for medical educators in Tyler’ experience. The educational universe is not Copernican, and we are not its center. At the center of medical education is the patient. If we are fortunate, sometimes important lessons flow through us, but they originate in the patient. Borrowing from Socrates, we are but medical education’s midwives, doing what we can to impart knowledge, but knowing full well that the patients are the ones who really bring it to life.