My question is..

How does my identity as a teacher align with the underlying value system that is expected of a medical graduate and how and where are these values being taught?

In the last blog I tried to define a few values that I thought were important for a practicing physician such as intellectual curiosity, mindfulness and professionalism. The comments after the post got me thinking of whether I agree with these definition or not and how I fit into the picture an if these values can be taught and if so where.

I think Intellectual curiosity is not different from critical thinking. Both ignite the same inquiry process that leads to purposeful unknotting of the threads of a messy yet structured ball of unsolved problems.

The first step of critical thinking for a medical students would be identifying red flags in a given clinical cases. Where can we teach this and how do I fit in?  In the anatomy lab, before an incision is made I ask the students to jot down any surgical scaring that they notice.  After which, I encourage the group to contemplate what surgical procedure the patient may have gone through. The only information they have about the “patient” is the cause of death. They hold on to this information and then confirm their findings upon complete dissection of that particular region.

  

In addition, more often than not we see pathology, variations from the normal and even congenital anomalies once we begin out dissections.  The resources they have are the books in the lab, internet and faculty members.  Using these resources they infer the best plausible explanation for the condition. The group of students’, who have observed this pathology/variation /congenital anomaly, are encouraged to discuss their findings with the whole class. This guides the students on why it is important to be observant and to confirm their observations with questions or tests. As clinicians it is beneficial for the physician and to be observant of every detail from the time a patient walks in present their case.  The sooner the physician can connect the various observations with the history the more efficiently a diagnosis can be made.  The lab allows the advantage of taking a direct look into how complications of one organ can very often affect structures and organs around them.

As my teaching philosophy inventory demonstrates I have a strong apprenticeship and developmental perspectives. As a facilitator, I see myself trying to channel the students to dissection by showing them the relevant of what they are learning and the clinical significance of the same.  As the result,  learners are able to demonstrate and explain their understanding; learning has indeed taken place¹.  Each dissection session has a clinical case attached to it. These cases are discussed from history taking -to chalking down differentials- to lab tests - to treatment and the case ends with the prognosis. The cases reinstate a real world scenario to the findings in the lab; this I believe makes the learning process authentic and deep.

Mindfulness is a value that keeps our feet to the ground, our eyes fixed on the person in front and our empathy is equal stride with the story presented. Mindfulness is being aware and sensitive to our own challenges and the variations that exist in the society via culture, gender, economical status and physical differences. We need to be comfortable with were we come from and how we interact with others on a one to one basis. In the lab, students are initially given time and space to feel and talk about death, the concept of learning from a donor and this learning is accepted with responsibility, respect and gratitude.

Probably the toughest part of being a medical practitioner is death and dying. As young zealous and industrious first year medical students are exposed to the anatomy lab; very often the feelings that overwhelm them linger through their lives.  In order to address these feeling; on day one in lab we participate in a memorial service. Students’ reflections from the previous year are part of this service. As a nurturer, I pay attention to and take care of the students who are unable to cope with their feelings. The most dominant teaching philosophy that emerged when I did the TPI tests was apprenticeship.  I try my best to be mindful of the students’ state of mind and in the lab make it very clear that the attitude of respect and gratitude is the least that is expected of them.  Thus learning in the lab is all about the process and product of education; which in accordance to the apprenticeship perspective is a definition of learning ².  

Professionalism as defined by ‘The Canadian stakeholders Coalition on Medical Professionalism’ is in my previous blog. (The Canadian Stakeholders Coalition on Medical Professionalism states: "Medical professionalism describes the skills, attitudes and behaviours common to those undertaking the practice of medicine. It includes concepts such as the maintenance of competence for a unique body of knowledge and skill set, personal integrity, altruism, adherence to ethical codes of conduct, accountability, a dedication to self-regulation, and the exercise of discretionary judgment. Professionalism is also the moral understanding among medical practitioners that gives reality to the social contract between medicine and society. This contract in return grants the medical profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation.")

Do I agree that all of the qualities need to me procured during the education years of a medical learner? Yes I do, but the other question is, are all these qualities teachable in the anatomy lab? How can I create the opportunity for the students to practice these values? 

In the anatomy lab, the climate is that of deep learning and respect. Students are shown respect and facilitators respect all human tissue in the lab. This respect and responsibility is infused in to the culture within the lab. Here students works as a group and learn to collaborate for a mutual beneficial learning³. They present their findings and assessments as a group. I try to bring in inter-professional interactions by calling in Physiotherapist and clinician to assist in the lab. In the process, the students get to interact with other professional and understand the different roles played by the various professionals.

The teaching philosophies that emerge in the lab are that of apprenticeship, developmental and nurturing. 

1.       Ric Arseneau and Dirk Rodenburg; The Developmental Perspective ,Cultivating Ways of Thinking; Teaching Perspectives Inventory,  Chapter 6 .

2.       Janice Johnson and Daniel D. Pratt, Modelling ways of being; Teaching Perspectives Inventory,  Chapter 5 .

3.       William J. Swartz; Using gross anatomy to teach and assess professionalism in the first year of medical school.  Article first published online: 8 MAY 2006; DOI: 10.1002/ca.20331

Inquiry

TPST: Assignment 2: September 21, 2012

Question: Why and how is it important for medical experts to be intellectually curious, intentional and mindful professionals?

Assumptions:

1.      Curiosity, intentionality, mindfulness and professionalism are important or essential to practice medicine.

2.      All of these traits can be taught and learned at a medical school.

3.      All of these traits are compatible with each other

Before I move on to discover some deep thoughts on this question I would like to consider what the definitions of these terms are and how they are related to one other.

Intellectual curiosity: is there any other form of curiosity?

¹Thane Stenne, journalist for Global mail, articulated a common thread that runs in successful investors as follows “However, what is a common trait in virtually all of them is that they are “intellectually curious.” They love to learn. They look for insights, always a better way of doing things… an “edge.”

In medical education, it is getting more and more evident that to set the students up for success in their individual medical careers, it is for paramount importance to be intellectually curious.  The entire process of diagnosis and prognosis is based on asking the right questions and getting all the information possible from the patient. If a physician neglects to ask about a particular detail, that very detail maybe the cause a misdiagnosis². Where and how do we instill this sense of curiosity in the student or do they come into medical school because this is one of their strengths. The reason I say this is because increasingly medical school are looking for not just the grades and tests scores during the admission process but also for a few key characteristics in the individual. This shift from mere intellectual abilities to a blend of characteristic needed to function effectively as a physician impregnated the field of medical education as early as 2005³.

Can we take for granted that intellectual curiosity can recognise the boundaries when intellectual curiosity clashes with ethical issues⁴?

Intentional learners are not only inquiry based but also self-motivated and responsible for their own learning⁵. Medical students are flooded with information at a very rapid rate daily in a regular school day. What learning and the depth of learning the individual students get out of it each day is entirely up to them.

Mindfulness seems to me like an art form of medicine or any profession. We need to get the message across in a respectful and sensitive manner. Doctors very often have to have the heart to empathise with the patient and the head to make the right decisions for their patients’ wellbeing⁶. Are we able to elicit these similar situations during their education? Do we train them to be mindful?

Professionalism: Direct quote: The Canadian Stakeholders Coalition on Medical Professionalism states: "Medical professionalism describes the skills, attitudes and behaviours common to those undertaking the practice of medicine. It includes concepts such as the maintenance of competence for a unique body of knowledge and skill set, personal integrity, altruism, adherence to ethical codes of conduct, accountability, a dedication to self-regulation, and the exercise of discretionary judgment. Professionalism is also the moral understanding among medical practitioners that gives reality to the social contract between medicine and society. This contract in return grants the medical profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation."

Assumption 1 and 3: Curiosity, intentionality, mindfulness and professionalism are important or essential to practice medicine. Are these compatible?

All of these traits are indeed compatible as one feeds into the other. Intellectual curiosity in students makes the experience of learning more student-centered. The students who are motivated to research and take responsibility of their learning are very often intentional learning.  Mindfulness is the art of medicine while Professionalism is the act of medicine. The two are part of developing both the intellectual quotient and the emotional quotient within the individual.

Assumption 2: All of these features can be taught and learned at a medical school.

Medical school in North America are explicitly and inexplicitly incorporating these aspects of training as part of medical education. These are often competencies that are common themes running through the years of medical education.

As a medical educator, I can connect with all of these traits. The anatomy laboratory sessions are great teaching opportunities to foster these traits. As students come in to deal with cadaveric tissue, the emphasis on respect and professionalism are explicitly cited and practiced. The students learn to work as a team together with mindfulness and intentional learning.  

1.      http://www.theglobeandmail.com/globe-investor/investment-ideas/the-secret-to-success-intellectual-curiosity/article4217614/

2.      Dyche L, Epstein RM; Curiosity and medical education Med Educ. 2011 Jul;45(7):663-8. doi: 10.1111/j.1365-2923.2011.03944. http://www.ncbi.nlm.nih.gov/pubmed/21649698

3.      REPORT OF THE COUNCIL ON MEDICAL EDUCATION; 2010. http://www.ama-assn.org/resources/doc/council-on-med-ed/cmereport3a11.pdf

4.      http://goodgeneration.org/2012/02/04/in-search-of-meaning-why-intellectual-curiosity-is-not-enough/

5.      http://www.trainingplace.com/il/

6.      http://yjhm.yale.edu/essays/tkelly20100425.htm

7.    http://www.cma.ca/index.php/ci_id/3300/la_id/1.htm

8.    Linda Blank; Medical Professionalism in the New Millennium: A Physician Charter; Ann Intern Med. 5 February 2002;136(3):243-246. http://annals.org/article.aspx?volume=136&issue=3&page=243

Teacher –student metaphor: Sheepdog and grazer/wanderer:

I believe that students are depending on the teacher to guide them to the right pastures of awareness and knowledge. As teachers we take the time to filter through extensive information and various resources, summarize key points that the students need, before it is presented to them. The pastures are the information patches that we as teachers have meticulously assembled for the class.  Students are given limited time to graze through the information.

 In the large scheme of learning, teachers are trusted by the students to nudge and forge them ahead in to a safe zone. The pastures provided are more open ended so that they have access to other resources. In medical education, anatomy is one of the many pastures the students will graze and explore through; thus as a guide, I would like to direct them to nourishing pastures. Once they have a chance a feed on the pastures, it is my duty, similar to that of a sheep dog, to direct them to a study area where they can digest the new information, interact with co-learners, have open discussions, and prepare for the next stage.

Sheepdogs are known for their bravery in taking risks, if need be, to ensure that the flock is safe. As a teacher, I am willing to try out new teaching methods and take the risk of a new approach. This new approach may or may not work. However, I am willing to put myself out there and test the waters. I am dedicated to the learning needs to be achieved in my field and understand fully well how it fits into the curriculum of medical education. Like the sheepdog, I like to allow free range of thinking and space but, if and when they go astray, I will be the first one to go searching for them. This search may sometimes  prove challenging but I would still be the advocate for the student that needs the extra help, which, I am more than happy to offer.

As grazers, the focus is not always on quality but on quantity. At times a toxic plant could look more appealing and the grazers may forget to follow direction, and chase the inappropriate senses. More often student focus on the results than the learning itself. Students may be tempted to fill their projects with irrelevant information to make it seem well researched. Students want the best out of the program and tend to measure the exam results as a testimony of their learning. The true learning is in the path/s they chose, and in the connections they make with the different pieces of information gathered.

Students are aware of the authority exercised by the sheepdog, and heed to the call when asked to think from a different angle. They understand that moving on is part of the learning that takes them to the various stages of their education. Students respect the safe environment to  openly discuss various issues that they feel may be encountered in practice of their careers.

Thus, as a teacher, I see myself as a sheep dog and my students as grazers.