Does your attending physician really know how to teach?

Our educational system rewards zebra finding more than conserving financial resources.  Too many academicians think zebras first and then default back to the obvious diagnosis.

One problem stems from our educational process being haphazard.  Rarely do we select attending physicians for teaching skills, or teaching philosophy.  We get faculty generally from three buckets:

  1. Research future: Can they get grants funded and produce important research?
  2. Clinical expertise: Will they attract complex patients to the academic medical center because they are the expert for a zebra disease?
  3. Clinical need: Sometimes we just need another body to see patients in clinic, or do endoscopy, or do cardiac caths.

Only occasionally do we focus on teaching as a reason to hire someone.

When we hire any new faculty, we assume  that they can teach, and that what they will teach will have worth to the students and residents.  We do not really have department education goals.  We have a written curriculum that everyone ignores.

Some attendings do not go zebra hunting.  Some of us assume a horse (rather than a painted zebra), but will look for the zebra once the paint starts to crack.

I better write that concept more clearly.  The diagnostic process works best when we try an obvious diagnosis, and see if the patient’s problem representation (a short synopsis of their presentation) fits our illness script for the obvious diagnosis.  We should consider alternative diagnoses when the patient’s story does not really fit the illness script.

The key to zebra hunting is knowing when to hunt.  We owe it to our learners to make that decision explicit.  The onus of teaching this type of diagnostic decision making should fall on the entire faculty.  But first we would have to teach them some teaching principles.  And since teaching is, in my opinion, undervalued we will in the near future teaching students and residents that zebra hunting is a primary passion without regard to appropriateness.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • Robert Bowman

    This is a great post that points out the consequences of 100 years of separation between practicing clinicians and medical education with movement away from clinical, teaching, and health access focus. It has been a great eye opener to be at a school that challenges me to be the best clinician, the best teacher, and the best at health access. SOMA has 65% of the first year medical student contact time delivered by clinicians. Not surprisingly we have faced challenges finding clinicians who can teach first year medical students, teach clinical skills, write objectives, write test questions, and shape a clinician specific training design.

    A scheme presentation design (teaching the way that patients present to physicians – ex. chest pain, dizziness) is a great help to organize the curricula clinically. Second, this osteopathic school is hands on in focus from the start with just as much time spent teaching clinical skills. Even after a lifetime of practicing and teaching, it took me 3 years teaching clinical skills before I actually had the skills to teach. As a result I teach and I practice more effectively and confidently. It takes time for clinicians-teachers to learn what 1st month, 4th month, and 7th month medical students can grasp. The model has required us to work closely with students and each other – another bonus but also a great challenge. There is more about the design at Clinician Specific Medical Education and Basic Health Access.

    For 100 years medical education has grow distant from clinicians, medical students, and most of the nation. The next 100 years must re-integrate all of the above and more. The challenge is great as the main way to restore such training is to recruit graduates of clinician specific training to become faculty while they are delivering health access where needed – restoring clinical training, medical education, health access, and health access workforce all at the same time.

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