Last week a friend who is a college chemistry professor shared a link to this piece on what students really seek from their best teachers, particularly at the collegiate/ adult learner level. The author highlights a few principles I have long held are critical in higher education, both at the undergraduate and graduate level: critical thinking must be fostered, small group /individualized learning experiences are necessary to do so, and that it’s okay to ask your students to do hard things as long as they know that you actually care about them.
One of the key challenges for those who teach in the medical setting is how we can objectively assess clinical reasoning skills. They’re not captured on a MCQ exam, nor necessarily on an OSCE. These are instead the clinical decisions that we see people make and that we ask them to explain to us, and convincing ourselves that just because they aren’t adhering to our personal dogma on a topic doesn’t make them wrong. An ancillary discussion is that of how to best teach clinical reasoning. Is it by “thinking out loud?” Is it by putting residents into challenging situations with a safety net in the form of an attending readily available to gently guide plans as they develop them? I’m reminded of an attending in my residency who let me make a mistake in the OR that he could see coming. His unflappable response when I did it (after he put his finger onto the bleeding vessel) was, “Well, what are you going to do about THAT?” It wasn’t asked in a threatening way, simply in a way that told me that I had created a little but fixable mess and that he was going to support me as I repaired it. It was an important clinical and educational lesson for me, and it is a model I have tried to incorporate into my own teaching. At the end of the day, none of us seem to have the answers to questions about how to best teach and assess in this realm, though it is clear to all of us that one of the most important things we do when teaching is to foster clinical reasoning skills.
Individualized learning, while something that intuitively we would anticipate in medicine, has not been something we have done well. It’s honestly much easier to design a one-size-fits-all, time-based educational program so you know exactly how long a resident will be on a particular service. Service, though, is the key word here, because the time-based education system hasn’t been used to individualize education, but instead to keep attendings “fluffed.” The present migration to Milestones in training ultimately has the potential to move us entirely away from time-based training to a competency-based model that would be far more learner-centered than what we’ve done since the time of Halstead.
Finally, the emotional/ interpersonal component of being an exceptional teacher that was noted in the link above. While I find the author’s description of what students want as being a mentor to be asimplistic view of what a true mentor does, my own research shows that medical students do define an attending surgeon mentor primarily through their role as a teacher. My own experience tells me that students and residents can be pushed, and pushed hard, as long was we do it in a way in which they feel supported and as long as we do it in an environment that is predicated upon mutual respect. To brag a bit on our Burn Unit, Burn has historically been known as a rotation that is busy, with hard physical and emotional work. It also is traditionally a popular rotation, particularly amongst the 3rd year medical students. I have always believed that it is because the attendings have been engaged, that their passion for their work is obvious, and that as a learner while you are given some measure of limited autonomy, you always know that the attending has your back. This was the culture there when I was a resident, and I believe we have continued to foster and maintain that environment. Does it make us mentors? Sometimes. Does it make us good and effective teachers? Definitely.