by Tim Lacy
After having some time to settle into my position—to read more broadly on the particular issues of mistreatment in medical education, and to visit with the UI-COM campuses—I have arrived at a tentative thesis about potential sources of mistreatment, broadly, in medical education:
In this corner of the professional world, mistreatment, it seems, is a result of misdiagnosis.
The judgments and processes involved in misdiagnosis occur in several vectors. And those vectors work between several populations in medical education. But the language of diagnosis and treatment provides, I think, a useful framework for understanding how and why things go wrong. This language might also help point the way toward corrective actions.
Generally speaking, mistreatment complaints tend to come from students and are about instructors—whether residents or physicians. While blame certainly may rest in the faculty group, thinking through their professional situation may help us avoid imputing them too much. There are factors with students that exacerbate the situation. This essay empathizes with both parties to help promote understanding, and maybe to open the door for solutions.
Even when physician-instructors desire the best for their students, they exist at the nexus of a number of pressures. Their habits of mind develop in relation to those pressures. Given that all MDs are trained to diagnose and treat, it is natural for them to carry those habits of training and thinking into other areas, including teaching. In the current health system environment, they are pressured to take quick histories, critically absorb or distrust the patient’s presentation (whether via physical appearance or verbal narrative), assess the range of symptoms, order appropriate tests, diagnose quickly, and prescribe treatments accordingly. An assembly line mentality may develop among some. The larger operational atmosphere, or business management climate, demands efficiency, as well as accuracy and success.
With students, this approach does not translate. While, philosophically speaking, both teaching and medicine are maieutic, ideally, in that teachers dialectically bring forth new ideas and knowledge, and health professionals bring forth health and wellness, in practice those ideals are smothered with procedures. The critical thinking skills that make one a great doctor do not translate directly into great teaching.
Given these habits of mind, the doctor-teacher is inclined to make a quick diagnosis of the student’s learning difficulty. But the tools for assessment are both inconvenient and inefficient. There is no time to obtain a proper history of the student’s misunderstanding. Quizzes (verbal or paper) only tell you what is present or absent, not why something is missing. Informal presentation factors, such as physical appearance or markers, have no bearing on the student’s mental processes. Couple that with the infinite variety of intellectual factors in a person that may prevent understanding, and the complexity overwhelms the physician instructor. Even resorting to one’s own educational experiences and history does not transfer, courtesy of changes in K-16 education and socio-cultural factors (i.e. generation gaps).
Students, too, have trouble with self-diagnosis. The proverbial “fire hose” of information conveyed in medical school overwhelms previously adequate systems of information storage and retrieval. This is acute in the first two years and leading up to the Step 1 exam. But the feelings of being overwhelmed continue into the M3 year, as students adjust to balancing floor assignments, new learning environments, new staff, and traditional study and exams. In terms of instructor-learner dynamics, there are also traditional concerns: the power differential and fears of being shamed or embarrassed over a potential lack of proper study (a shame that exists even when study has occurred). Altogether these factors cloud a student’s self-diagnosis.
The resultant mix of concerns might make one wonder how any learning occurs in medical schools. But it does and, amazingly, functions moderately well, most of the time. The system has been stable for some time, and works widely—across different institutions, regions, and with different populations. But the ongoing democratization of medical education has exacerbated tensions embedded in the model.
Given these tensions, there should be little wonder at why it occasionally breaks down. Both instructors and students swim in a sea of complexity. When the teacher-learner relationship breaks down, it is natural that frustration will exist in both parties. The pressures of medical environments, and the internal pressures of students and doctors (i.e., perfectionist tendencies, high motivation, driven), enable the possibility of human reactions, or overreactions. They happen. Faulty attributions will arise. Inappropriate language will be used. Accusations will be attendant, and blame will be assigned. (Nobody wants to be seen as irresponsible.) Given these problems and frustrations, it is not surprising that real and perceived mistreatment occurs.
What will help both parties avoid overreactions, or even just reacting, is a better vision of the diagnostic work involved in medical education. This involves an acknowledgment of the complexities in the transfer of knowledge, and in students’ lives. Given the power dynamics and hierarchical structure of medical education, the burden of being calm and reasonable is first on instructor-physicians. Instructors must acknowledge the legitimate complexity in the lives of their student charges. Students are in the best position to diagnose their reactions and the situation at hand. Even so, students have a responsibility, as developing professionals, to know, or try to articulate, what is problematic. The burden is on them to be as self-aware and direct as possible. They must confess weakness and, when possible, failures in understanding. Instructors, in turn, must operate from a default position of trust. A suspension of criticism and collegial trust must replace the tendency to distrust the student’s presentation of their learning issues. Diagnosis regarding educational problems is a mutual process.
All parties will treat each other better when they work, to the utmost, to better diagnose the pain points in transferring skills and knowledge. Physicians and aspiring doctors must, to paraphrase an old saw, diagnose themselves(!)—better and more accurately.