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Tips to teach young physicians about more than just disease

Copyright © 2003 by the American College of Physicians.

By Edward Doyle

SAN DIEGO—When it comes to teaching medical students and residents, medicine sometimes shortchanges not only individual physicians, but the profession as a whole.

At an early April workshop for chief residents held by the Association of Program Directors in Internal Medicine (APDIM), Kelley M. Skeff, FACP, said that too many medical educators believe their primary job is to teach students and residents about disease. But because medicine is undergoing radical change, he said, teaching about disease is no longer enough.

Dr. Skeff, a residency program director at Stanford University in Stanford, Calif., and a well-known expert on teaching, urged internal medicine's next class of chief residents to teach residents and students to take responsibility for problems in medicine. To do that, he gave them tips on how they can make the most of teaching opportunities.

While his tips were geared to chief residents, they offer lessons for internists who teach students or residents in the office, or work in community hospitals. Here are some of the pointers he gave:

  • Don't pretend to have all the answers. Too many doctors try to pack as much content as possible into a presentation to establish their authority. Dr. Skeff said this approach not only bores learners but can lead to serious problems.

    He said that chief residents in particular regularly have to field questions they simply can't answer. How you handle those moments, he told audience members, will profoundly influence residents and medical students.

    If you try to hide your lack of knowledge about a topic, Dr. Skeff said, you're telling younger colleagues that it's wrong to admit that you have knowledge gaps and that you're fallible.

    The long-term fallout of that attitude can be devastating, he explained. To make his point, he pointed to medical errors. While the now-famous Institute of Medicine report said that medical systems, not individual physicians, are to blame for many preventable errors, Dr. Skeff said physicians bear some responsibility.

    He said that doctors' efforts to hide knowledge gaps have likely worsened the problem of medical errors. Instead of trying to get around a difficult question you can't answer, he said, deal with knowledge gaps openly and honestly.

    "We need to share our gaps in knowledge and our mistakes," Dr. Skeff said. "We need to discuss them and solve them to keep our colleagues from making the same mistakes."

  • Teach more than disease. While medicine has typically focused on teaching about disease, Dr. Skeff urged chief residents to consider teaching about other areas, such as public health and the practice environment.

    "Medical educators believe that they have successfully trained you as a physician if you know everything about disease," he said. That leaves residents to learn about other aspects of medicine on their own, a strategy that he said is not particularly effective.

    In today's practice environment, he pointed out, physicians no longer work alone, but as part of teams. Many have not adjusted to the role very well. Too often, Dr. Skeff said, physicians are out of sync with the institutions where they work, in large part because of how they are trained.

    Right or wrong, he said, physicians too often come across as whiners who complain about problems in their organizations without trying to fix them. He said that chief residents can use their influence to change that perception about physicians, while improving the image of individual doctors and the profession as a whole.

    "If other health care professions continue to see us as people whose goals are opposed to the system in which we reside, we will never play a role in improving that system," he said.

    "Our system's goals must be in sync with our profession's goals," he said. "Learn about the system and teach your residents to become a part of it, and the profession will be better off 10 years from now."

  • Encourage professional behavior. When Dr. Skeff asked audience members if they had heard others badmouth a colleague's performance, most agreed. When he asked what happened as a result, however, many in the audience acknowledged that no one ever took any action.

    While gossip and backbiting may be a part of most workplaces, Dr. Skeff said it undercuts professionalism in medicine.

    "We've trained you to be able to talk about suboptimal performance and do nothing about it," he explained. "How can we tell the public that they can trust us as professionals when we're willing to talk derogatorily about our colleagues but do nothing to help them improve?"

    Instead of putting up with the status quo, Dr. Skeff urged chief residents to use their influence to prepare the nation's future physicians to help change and improve health care. Because of all the changes taking place, he said, this could be an exciting time for American medicine if the next wave of physicians is ready to accept the challenges that lie ahead.

    "You have the potential to redefine what the profession will be," he told the audience. "If you can maximize your own and your colleagues' abilities to contribute to the field of medicine, I guarantee your institution will improve."

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