Self-learning Clinical Medicine under the Guidance of a True Teacher

The standard methods of teaching clinical medicine are stated. Lectures are simply sources of information that may not always be understood or used by the listeners. Lecturers are not true teachers, because they have no feedback from the listeners. Certain aspects of self-learning are described. This method of learning, guided by a true teacher, should be mastered during internship and residency. Self-learning places patients at the center of the activity where doctors care for them and simultaneously learn medicine by asking themselves questions about their patients and searching for the answers. A clinician who learns medicine using this approach may know more about a problem than can be found in standard textbooks. Textbooks discuss the general rules about an illness, whereas the expert clinician may know the exceptions to such rules. The self-learner always correlates the data found by one technique with the data found using other techniques. This approach improves all skills, including thinking. The self-learner must teach. This discipline demands that trainees organize the data they collect and improve their skill of communication. Finally, trainees should learn early in their training that good doctors make many types of decisions about their patients, and such decisions must always be made in favor of the comfort and convenience of their patients.

J. Willis Hurst, MD, MACP

Division of Cardiology

Emory University School of Medicine

KEY POINTS

• The habits of self-learning must be developed by house officers under the guidance of a true teacher.
• House officers must place their patients at the center of their activities.

This essay has no end, but of course it must end. The current methods of teaching medicine seem to be failing because clinical teachers are using the methods that are used in undergraduate schools. There must be a new thrust in the self-learning of clinical medicine under the guidance of true teachers. An approach to this type of learning is described in this manuscript. This essay is aimed for the most part toward medical house officers who are often referred to as trainees.

The True Teacher

Little is stated here about the attributes of a true teacher, who is very different from the pseudoteacher who only announces information.¹ A true teacher is a facilitator who guides trainees to think. Such teachers have a long-term and personal influence on the trainees with whom they are associated.

A trainee's view of teachers usually changes over time. The full impact of a true teacher may not be realized by the trainee for many years after the trainee has left the institution. Some years later, the trainee will remember only a few facts the true teacher dispensed, but will remember that the true teacher emphasized that compassion for patients would lead him or her to study, which, in turn, would lead to competence; that the true teacher taught the trainee how to collect information from patients; that the true teacher taught the trainee to think; that decisions should always be made in favor of the patients' well-being and comfort; that the true teacher insisted that the trainee listen to patients and be responsive to them; that the true teacher urged the trainee to link his or her reading to the patients' problems; that the true teacher insisted that the trainee should seek help when he or she did not know; that the true teacher taught the trainee to communicate properly with patients by pen and mouth; and that the true teacher insisted that the trainee seek excellence in work and feel proud of the profession he or she had chosen.

Trainees can learn medicine without the guidance of a true teacher, but I agree with Kenneth Ludmerer² who quotes Osler: "An academical system without the influence of teachers upon pupils, is an Arctic winter."³

Mortimer Adler wrote this cogent statement about the true teacher: "Speaking simply and in the broadest sense, the teacher shows the student how to discern, evaluate, judge, and recognize the truth. He does not impose a fixed content of ideas and doctrines that the student must learn by rote. He teaches the student how to learn and think for himself. He encourages rather than suppresses a critical and intelligent response."⁴

Methods of Learning Clinical Medicine

At the onset, it is important to accept the view that recent graduates of medical schools are not skilled. This is not the fault of the students or the medical schools they attended. All medical school can do is introduce students to skills, including cognitive skills. Accordingly, skills, including cognitive skills, must be further refined and perfected during house staff training. This is why house officer training was created. The habits of self-learning must be developed by house officers under the guidance of a true teacher, because this form of learning is the major method of learning after a trainee leaves the teaching institution.

The teaching methods generally used during the period of house staff training are listed in order of value in Table 1.

Whereas all these methods of learning clinical medicine are somewhat useful, the best methods are self-learning under the guidance of a true teacher and teaching ward rounds with a true teacher. The poorest method of learning is listening to lectures. At best, lectures are simply a source of information. Regrettably, if the information is not used, it usually vanishes from the listener's brain. This is why lectures are not considered to be a method of teaching. Any seasoned true teacher understands that clinical skills, including cognitive skills, cannot be learned at lectures.

Suggestions for Self-learning Trainees

House officers should realize that they are continuing a course of study that they started in medical school, but that school is not over. Trainees must perfect their clinical skills, including cognitive skills, during the 3 to 6 years of house staff training. Equally important, trainees must learn how to deliver what they know in a compassionate manner. They must learn how to be their patients' advocate and, being responsible for their lives, they should care deeply for them (Table 2).

• House officers should place their patients at the center of all their activities.

Trainees must learn to sense if they have earned the trust of the patients assigned to them. This necessary feeling on the part of patients is commonly earned by trainees when they take the medical history of the patient. If trainees take the patients' history like trial lawyers, or show indifference to the answers to questions, the trainees may be viewed by the patients as noncaring and insensitive doctors.

• Trainees must teach nurses and should permit nurses to teach them. Trainees should teach their peers and should encourage their peers to teach them. It is sad to witness one house officer attend a patient with myasthenia gravis in one room, and in the next room a patient with carcinoid syndrome is being attended by another house officer, but no interchange of knowledge occurs between them. Trainees must teach, because teaching demands that they organize the information about the subject. Trainees should jump at the opportunity to give a lecture, because they will learn from it; in contrast, they should not attend many lectures because, as a passive listener, they will learn very little.

Trainees should identify a radiologist, an electrocardiographer, and a pathologist who like to teach and are willing to discuss a patient's problem with them.

Trainees must develop their skills of leadership as they move from being an intern to becoming a resident. Advanced residents should help and guide the interns who are assigned to the same patients. This is proper, because house officers will soon supervise and direct their office personnel when they begin practice, or they may choose to remain in academic work, where leadership skills are commonly needed.

• The modern database has replaced the old history and physical form.⁵ The house staff program director is responsible for creating a form that should be completed by the house officers, medical students, and physician assistants or nurse clinicians. The form lists items that should be collected to screen the patients for disease and potential disease, as well as items that require the development of the skills needed to become competent in the examination of patients.

Trainees should look up the significance of the abnormalities they discover in their patients and must understand the physiologic, biochemical, and pathologic mechanisms involved in normal and abnormal findings. This may require the help of a true teacher and a review of the appropriate sections of a physiology book, a biochemistry book, a pathology book, other textbooks, or the Internet. True teachers may facilitate the effort by supplying references that are germane to the subject, but trainees themselves must do that when the true teacher does not.

• Knowledge about a skill, including cognitive skills, is not sufficient. Trainees must practice, practice, practice under the supervision of a true teacher until their own skills are fully developed. We must change the current superficial approach of gathering data because it is apparent that some trainees cannot take an accurate history, auscultate the heart, examine neck veins, or interpret laboratory data or an electrocardiogram (ECG).

Trainees should develop the habit of saving interesting material about their patients. For example, they should make copies of interesting ECGs of their patients and keep them in a notebook. The importance of the ECG will be enhanced when a trainee correlates the data found in the tracing with the other data he or she collected from the patient.

• Self-learners appreciate the problem-oriented record. This type of record, created by Weed,⁵ encourages the completion of a Defined Database, the creation of a numbered Problem List that is based on the data, and the development of Initial Plans and Progress Notes. The Initial Plans, including orders, and the Progress Notes are identified by the same numbers that were used to label the problems on the Problem List. This forces trainees to organize the plethora of data they have collected into diagnoses or statements based on the data. This encourages the house officer to think.

The true teacher should ask each trainee the following 2 questions about the problem statements they create on individual patients:

"What data did you use to formulate the problem as you have stated it?" If one defines thinking as the rearrangement of information to create a new perception, it is possible to ascertain if the trainee is thinking properly with the data collected. The true teacher should judge if the trainees know the criteria needed to make the problem statement. If they do not know the criteria for diagnosis, the true teacher should ask the trainees to look it up.

• The true teacher also asks a trainee, "Are all significant abnormalities that you collected accounted for on the Problem List, either as attributes of a diagnosis or listed as a separate problem?" The true teacher may discover that the trainee does not understand the meaning of the word "significant" as used in this context; it means any abnormality identified in the database that could influence the patient's current or future health. This includes the listing of tests or procedures used to prevent disease or to discover the early signs of disease. For example, if a patient older than 50 years has not had a colonoscopy or an elderly patient has not received an injection of pneumonia vaccine, their absence should be recorded on the patient's Problem List, and the plan for the correction of the omission should be stated.

Much more could be written about the teaching and self-learning value of the problem-oriented record. It can be used superficially, and the trainee may learn very little, or it can be done with deeper understanding, and the trainee will learn a great deal. Done properly, it is a true teacher's dream, because the trainee has made a commitment in writing, and the true teacher's job is to agree or disagree with what has been recorded.

Trainees must retain their sense of curiosity: no curiosity, no learning. It is not sufficient to simply create a problem-oriented record. Trainees must always ask "why" about many items they observe and record. The rule must be: trainees should look up something on every patient they see. They should use a textbook or the Internet to find the answer. The true teacher can judge the competence of a trainee by the questions the trainee asks; no questions, no learning.

Information presented by a lecturer is often forgotten by those who are in the audience, but answers looked up by a trainee about a patient are usually remembered.

As developing self-learners, trainees will discover that there are 2 types of questions that must be asked and answered. One type deserves a quick answer. For example, if a patient states that he had an attack of gout 2 years ago, trainees should not accept the diagnosis of gout as absolute. This would be like accepting hearsay evidence as absolute truth. Suppose a trainee had never seen a patient with gout or read anything about it. The trainee should elicit every detail of the gout attack from the patient and, before the diagnosis is recorded, take 10 minutes to look up gout in a textbook or on the Internet. Having read about gout, the trainee may have more questions to ask the patient about his acute attack of arthritis. In this way, trainees will learn more about gout and remember it because the information gained by reading is linked to the specific patient. This is known as the "short read." The reading is designed to answer a question about a patient immediately.

The other type of question deals with the understanding of a disease process. If trainees wonder or ask why occlusive coronary artery disease exists, this requires a "long read." A trainee must set aside several hours to study the atherogenic process. A lecture on the subject, without reading and study, will not necessarily improve the trainee's knowledge of the subject.

The smartest physicians ask themselves questions about their patients and have the self-discipline to search for the answers.

The correlation of data is a major learning tool for the self-learner. This technique is best illustrated by examples.

When a trainee diagnoses unstable angina pectoris due to coronary atherosclerosis, such an opinion should match the abnormalities found in the coronary arteriogram. If it does not match, what is the trainee's next thought and plan?

When an ECG reveals right ventricular conduction system block, did the trainee detect the abnormality on auscultation of the heart or did the trainee fail to listen specifically for the abnormality, which should always be done.

The trainees should be able to determine the presence and severity of mitral valve stenosis by auscultation. When a trainee correlates data collected by physical examination with the data collected by echocardiography or cardiac catheterization, the trainee will gradually improve his or her auscultatory skill.

The trainee's routine examination of the patient will gradually improve when he correlates the information obtained by high-tech procedures with the data collected by the trainee's routine examination of the patient. The results of high-tech procedures should serve as a teacher to improve the skill used in the trainee's routine examination. Errors can also be made in the high-tech laboratories that may be evident from the routine examination, if the examiner is competent.

The practice of medicine can be divided into 2 parts. One is the acquisition of medical knowledge that keeps changing. Self-learners know that and continually update their knowledge as described above. They can date when they last looked up the answers and will update their knowledge when the need arises.

The second part of doctoring is to know the sick individual as a person. Different patients react to the same disease in very different ways. For example, a trainee should not simply record that the patient's problem is arthritis on the Problem List. Trainees must state the etiology and record what joints are involved. How much does the arthritis interfere with the patient's life? The patient's reaction to the disability must be considered and recorded. Patients need to know that the trainee, as their physician, understands how they view their situation.

Trainees must remember that the purpose of house staff training is for them to learn how to learn. The trainees' formal training will be over in a few years. Thus the habits and actions of a self-learner must be learned during house staff training because the trainees' teachers will eventually be referred to in past tense.

Trainees should be on time at every scheduled activity. After all, the habit of being on time must be carried out when the trainee later practices medicine. It is rude to be 15 minutes late to a teaching session. It is also disrespectful for a patient to wait 2 hours to see a practicing physician. It is understood that an acute illness of another patient may detain trainees, a house officer, or a practicing doctor. Should this occur, the trainee or practitioner must learn how to explain the emergency to the waiting patients.

When making a decision about patient care, physicians must be sure the decision is made in favor of the comfort and convenience of the patient and not of the trainee or the practicing physician. For example, it is barbaric to schedule an outpatient procedure on a 90-year-old patient for 7:00 AM or ask the patient to drive 40 miles to be at the hospital by 5:00 AM. Trainees must appreciate that the best doctors give a bit of themselves to every patient, and patients are far more comfortable knowing that their doctor cares about them.

A Final Comment

Self-learning is the most important method of learning medicine. A true teacher can help trainees self-learn. This communication emphasizes some thoughts and actions that are needed by a trainee to accomplish this goal.

The subtle message to the trainee is that it is absolutely correct to choose a hospital to train where there are many true teachers. However, as discussed in this article, there are a number of things that the trainee should bring to the educational table to achieve excellence.

Teaching Medicine: Process, Habits, and Actions.

1. Hurst JW. Atlanta, Ga: Scholars Press;1999:13-17, 27-40.

N Engl J

Med.

2. Ludmerer KM. Learner-centered medical education. 2004;351:1163-1164.

Aequanimitas with Other Addresses

to Medical Students, Nurses and Practitioners of Medicine

3. Osler W. Teacher and student. In: . 3rd ed. Philadelphia, Pa: Blakiston; 1932:26.

Great Ideas from the Great Books

4. Adler MJ. . New York, NY: Washington Square Press; 1966:117.

Medical Records, Medical Education, and Patient Care: The

Problem-Oriented Record as a Basic Tool

5. Weed LL. . Cleveland, Ohio: Case Western Reserve University Press; 1970.