[image credit TSgt Manuel J. Martinez/DOD]
I can’t help but comment on a recent post on KevinMD regarding the teaching of medical students, “Reward or punishment in medical education”. The author, a physician and pediatric intensivist, discusses what to do when “a student does a poor job.” Most of the discussion centers on whether to provide negative reinforcement, and the role of mean reversion (“regression to the mean”) in causing observers to overestimate the efficacy of negative reinforcement. At the end, the author mentions a reference to the famous book by the Monks of New Skete on dog training – so I’ll talk about that a little too. First, though, I want to outline what I see as the biggest problem in clinical medical education.
In the clinical years, the biggest obstacle to improving medical student performance is not what kind of feedback you get – but rather that most of the time no one gives you any feedback at all. In my pediatrics rotation, weeks would go by without anyone giving me any structured feedback at all (other than “good job”). Then, an attending would come on service who wanted to teach, and they would at least make an effort to give some feedback after every patient presentation or at the end of each day. I appreciated this greatly and it made me want to work harder and be more conscious of my patient presentations and work on rounds. Then I changed services, and was back to being ignored. And, to be clear, I’m a pretty outspoken individual. I’m pretty aggressive about pursuing feedback even when it isn’t given. I’d say 8 out of 10 times I’d ask an attending or resident for specific feedback on something I could do better, they’d look at me blankly and say “oh, I thought you did a good job.” Then, if I pressed them, they’d provide some generic commentary that had nothing to do with my actual performance.
On my surgical rotation, things were very different. Sure, you were ignored for most of the day. But when you were doing something, or presenting a patient, the residents and attendings definitely let you know what you had done well (and, what you needed to work on). Sure, there were times when I was given ridiculously inappropriate feedback (like the time an attending punched me in the middle of a case for not knowing t he embryologic origin of the structure we were dissecting). Because of the realtime feedback, I quickly learned how to present patients in their desired manner, how to be efficient, and how to work within the surgical team. Was it harsh? Yes, often. But it was honest and accurate, and I learned more from honest accurate feedback than nice vagaries.
Now, having discussed the state of medical education, I want to talk for a minute about the state of canine education.
My girlfriend and I have two dogs. We’ve trained them relatively well, and we spend a lot of our free time thinking about them. As anyone who’s trained a dog will know, you can get a dog to do almost anything with enough force. There are collars, zappers, even sticks if you’re into that sort of thing. But what you sacrifice along the way is some of the dog’s drive – their innate desire to work. Instead of harnessing this inner passion and shaping it, you simply train the dog to avoid punishment. And, so, the dog will do pretty much what you trained it to do – but everyone who watches your dog work will know how it was trained.
I’m not saying that we gave our dogs hugs when they pooped in the house as we were housetraining them. But, at the same time, we didn’t beat them either. Instead, to understand why a dog doesn’t do what you want it to do, you have to adopt its perspective. That doesn’t mean putting yourself in its shoes – because dogs lack certain human prejudices – but rather doing your best to put yourself aside and become your dog. You have to understand how your dog interprets your tone of voice, your gestures, your posture – and you have to have some understanding of what motivates your dog (not what would motivate you …).
Gee, that sure sounds like a lot of work! No wonder no one wants to do that for medical students. Still, in the event that anyone else is still listening, I’ll give a short list of advice for anyone who is teaching medical students:
1. When lecturing, know your audience. What day and time is it? What have we done already today? And, most importantly, what do we know / what don’t we know about the subject? Most of the time you can find these things out just by asking us!
2. Give real-time feedback. Make it specific and non-emotional. Give feedback about behaviors, not individuals. Saying “Good job” is useless, unless you specify what about the job was good.
3. Adopt a beginner’s mindset when teaching. Lead your learners down your thought process, from beginning to end. Teach your students how to THINK, instead of trying to transfer knowledge to them (the internet is better and bigger than you are).
4. Take time to teach every day. Believe it or not, students are actually paying to be here. Yes, there is a strong apprenticeship component to medicine, and that is all well and good. But we aren’t paying to be ignored for days at a time. As an attending or senior resident, you set the tone for the rest of your team. If you don’t teach, and if you don’t reward and praise teaching, and if you don’t protect time for teaching, then no one will.
PS. A great article in this week’s New Yorker about canine units, for those who are interested.