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.