The Bell Curve

MD teaching bell curve Those outside of medicine, I want you to know this: doctors are doctors because they know medicine. They are not doctors because they are great teachers. And who teaches future doctors? Doctors do. For students looking to learn, it’s the lottery of the bell curve. Will today’s doctor also be a great teacher, an ok one, or confusing? Most of us will end up drawing in the middle. This week it feels like I’m on the losing tail.

To the clinical tutors I have had this past week, this is my open letter to you:

If you ask me to take a patient’s history, then let me. Do not interrupt me because you think that asking her about her work with the church is irrelevant: I am trying to assess her physical activity and social support. This will of course vary if she simply attends or if she helps in community building activities. Savvy?

Every time you interrupt me, don’t kid yourself that it is for my benefit. You have, in your mind, the order of questions that you would ask. I know you think it’s the best, but it can’t be, because every single tutor has a different order. What you ARE doing is upsetting my rapport and rhythm, confusing both the patient and me. So, if your goal was to teach me, you’re steering us into rocks.

When I ask the patient, “So what brings you here today?” they always respond with their chief complaint. Never has one of them responded with “the bus” or “my Dad” or “my legs.” Every time you interrupt me to say that I should have asked that question in such a way as to preclude these responses, you are proving to me, beyond doubt, that you are only interested in finding ways to assert yourself. It’s like being taught by a smartass fifth grader. Stop it.

If there are two of you overseeing the group, agree beforehand as to which of you will be the leader. When you interrupt and contradict each other, it’s bad for both of you. My options here are to assume that one of you doesn’t know what he is talking about or that one of you is an egomaniac who has to assert himself. Nice teamwork.

If your goal is to mold students in your own likeness, then lead by example. If you quietly do an amazing job and explain to me why you make certain choices, I might just decide to emulate you. Slinging mud at other doctors and then bragging about being clean does not impress me.

How are these things not blindingly obvious?

When you pimp me, what are your goals? If you want to teach me how to think like a physician, then lead me with your questions in that way. If you want to show me that you know more, then please, continue to ask the same question repeatedly, basking in the six minutes it takes before someone’s dart in the dark hits your bullseye.

I feel like I owe you, the reader, an example.

The physician is asking us about the presentation of a complete break in the femur (thighbone) that is displaced (pieces are side by side). We say immediately that the thigh will be shorter (because the broken pieces slide up against each other since the attached muscles are still pulling). However, we were missing something.

“What else would you see?”
“Bruising?”
“What else?”
“Patient is in pain?”
“What else?”
“A bump where the femur is displaced?”
“What else?”

Pretty annoying, right? Doesn’t exactly have you thinking like a doctor, does it? Here’s my idealized version of the same conversation:

“Why is the thigh shorter after the complete break?”
“Because the attached muscles are still pulling.”
“Do those muscles simply pull in one direction?”
“No, sartorius is involved in external rotation.”
“So what else would the muscles do to the leg that is broken?”
“Oh, externally rotate it!”
“Correct.”

I haven’t had that tutor yet. I’m waiting for the law of averages to give me some time on that better part of the bell curve. When I get there, I’m going to try to become a sponge. For now, I’m trying to stay Teflon.

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2 Responses to The Bell Curve

  1. We have a new class this year that supposedly has the goal of introducing M1s to that kind of stuff early, too. We’ve only had fake patients (actors, I mean) so far, but each small group of 10 students or so has some doctor from a nearby hospital leading them. When I heard the doctors were basically just volunteers, not teaching staff or anything, I was a little skeptical, I guess because I was expecting the average (or lower) of the exact bell curve you described. But, the doctor my leading my group has actually been pretty good. Maybe it’s because it’s not part of his job to drill us on the informational stuff, and we know so little right now anyway, but he’s been teaching us and giving us practice in how to establish a rapport with a (fake) patient. I guess any experience is better than none for now — but of course, it’s easy to say since I think my teacher’s actually a pretty good one.

  2. PDT says:

    I’ve experienced the amazing ones a few times, and I’ve experienced the “shut up and let me lecture you” or “and? and? and?” ones many times more over. The key here, I think, is to be responsible for your own education. After learning something, devise in your mind a plan to re-teach that very thing if somebody were to ask you how.

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