Saturday, July 11, 2009

I Didn’t Join the Circus, So Why Must I Jump Through These Hoops?

One of the things that troubles me most as a teacher is watching medical students’ enthusiasm and curiosity deteriorate during medical school. Within about three months, I see them going from thinking about what they are learning to trying to pare down the material to what is likely to be on the next test. The competitive habits that got them into school provide a deeply debased motivation for studying—without knowing why, they fret about being AOA or getting into a competitive specialty . Few of them live in the present—as preclinical students, too many want only to survive to move to the clinical years. As clerks, they worry about buffing up their records to get into residency. Once in residency, I wonder if they ever recover the vitality that comes from being fascinated and engaged in learning something, thinking a new thought, or enjoying the unfolding of a new relationship .

Given the deadening effect of our current way of educating— or to be precise, training—doctors, I understand why the competing challenges of mothering appeal so strongly. With children, we have to live in the present (though we do also eventually transmit to them worries about their future and risk turning high school into nothing but a springboard to college). We can’t stop to study them for the next exam. Their development and our relationship to them propels us forward, and it is only in looking back that we see how much we may have learned in the last few days, weeks, months or years.
A lot of paper and ink is currently wasted by people pontificating about “adult learners,” postulating that they learn differently from children—because they have to incorporate new information into older structures and because they need to learn by doing rather than by rote. I often find myself doubting whether any of these theorists (mostly men, I might add) have actually watched children explore the world, puzzle out new information to figure where it fits with what they already know, and joyfully practice new skills.

I wish that I could be creative and persuasive enough as a teacher who draws on experiences as a mother to enlist others to think differently about how to engage and encourage students . Rather than spice up our lectures with video clips to entertain them, we should think about creating relationships with patients, peers, and mentors that both stimulate their felt need to learn things and reward them, immediately, for doing so. I know that a medical student will never learn the complexity of our profession in the unselfconscious, apparently effortless way that our children learn in their early years, but I think they long for it to be so, and I long to able to make it that way for them. But even if that is not possible, we need to think more about motivating them by stimulating curiosity rather than fear of failure, rewarding learning immediately rather than in the distant future, and engaging with them as teachers so that they in turn will engage with patients and be the doctors we would want to see when we get sick.


  1. Your post brings up several important issues about medical education which must be addressed. My curiosity and enthusiasm certainly did not deteriorate through medical school. In fact, first year was insanely boring because there was no patient for me to apply the information to. In fact it just seemed like the memorizing of countless facts for the purpose of memorization.

    I am not sure why your students' facination is waning - I would hate for them to be my doctor. Right now I am suffering through internship (actually not suffering as much as I thought I would), but it seems like I have no time to look up things that interest me because I am still learning the nuts and bolts of patient care.

    While in medical school I gunned for a competitive specialty only to find it boring and not in line with why I went into medicine in the first place. Every phyisician I know pushed me to pick something with good hours, good pay (surgical subspecialty). I suspect your students are under the same pressures.

    I encourage my students to see their patients and come up with a plan to deal with each of their issues. And right now I am too busy trying to re-learn the basics - amazing how much you forget 4th year - to teach them much of anything. What I do teach them is to independently a) ask questions b) find answers. Oh, and how to write good notes and where the cafeteria is. So far they love it and if I ever see a severe lack of enthusiasm coming from them, God help them because I may never get off my soapbox.

  2. Very thoughtful post. I kept a journal during med school and when I look at it now, I could actually see my enthusiasm morphing into depression over the course of my first term. I think by the end of my first year, I was clinically depressed, so couldn't get up much enthusiasm about anything. I don't think I was alone either. It's hard to maintain enthusiasm when you're under such tremendous pressure that you can't appreciate what you're learning, only worry about, Will I pass?? (In my school, it was a very legitimate worry... 10 people flunked 2nd year and had to repeat.)

  3. This is a great post and definitely one easier to grasp if you've been in the toddler trenches. They are so keen! to learn! everything! all the time! oh gosh will you just stop asking me questions for a second!! I too feel that wish to transplant that full-body, all-encompassing thirst to understand EVERYTHING to the med students I teach.

    I generally find them still fairly keen still, and they have a concept they should be understanding more than "just the exam", but it is definitely in a very burnt out kind of way. If you actually spend time with a few very early first year students, they are palpably different. Maybe naive? Sure, but nothing wrong with that. why do we have to knock that out of them so quickly?

    They are definitely more inspired by one on one contact with a mix of good role models, good mentors and good teachers (who may not all be the same person). And, god forbid, actual patients who are allowed to just tell their stories honestly.

    I do still use clips from House, Scrubs, Grey's Anatomy etc though. They contain casts of characters these students have come to know well over the years and may see as friends, role models or even mentors in a way. So using those clips and talking about the characters' decision making and communications skills is not necessarily as far from what you're discussing as you'd think.

  4. I am one of those med students that has burnt out along the way. I failed my entire first block and spent the first semester of med school worried that I would fail. I was finally diagnosed with depression and put on antidepressents, which I've been off/on since I started, basically. I have numerous friends with alcohol/drug problems who are on probation in school and are randomly tested. I think it's mostly bc of the way the system works, the inability to never back off and learn at your own pace, the lack of a safety net (nothing makes a student more concerned about "what's on the next test" than 100,000 dollars of debt in her face).... some of us lack enthusiasm NOT because we're trying to be competitive, but because we are simply trying to get through it.

    I am a fourth year now, and I will most likely refer to med school as a confusing haze. I wish it had been a great experience- I LOVED college and expected to feel the same about med school- but the atmosphere in medicine doesn't really allow for much exploration/creativity/individualism.

    -unhappy M4

  5. I can say that while med school has definitely had its ups and downs, overall I have enjoyed the experience. There are exceptions to this (block one that was all basic science, and the clinical rotations where I felt incessantly picked at and judged), but if anything I have enjoyed things more as I have gone through. I think this is because I have been feeling more and more like a doctor, and now that I'm taking time off to do a PhD, have had some time to stop and consider what I really want from my life and career, and which specialty will best allow me to do that.

    I think I might be depressed without this time off. There just doesn't seem to be enough time to make informed decisions about these things in med school, and it all comes crashing down on your head during 4th year. It's frustrating that in order to apply to things in the medical profession you need to do it 18 months in advance. Who the heck knows anything that far ahead?


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