Letters from Maine

Reflecting on Education


If you have a minute—and I suggest that you not invest much more than a minute—turn to the commentary section in the back of the December 2005 issue of Pediatrics.

There you will find an article by a physical therapist, Margaret M. Plack, Ed.D., and a physician, Dr. Larrie Greenberg, titled “The Reflective Practitioner: Reaching for Excellence in Practice” (Pediatrics 2005;116:1546–52). It's pretty heavy stuff, full of words like “constitutive” and “contextualize.”

One sentence is 74 words long. One reference, they say, compares “good evidence to a DNA double helix.” Now there's an analogy that's guaranteed to clarify. It turns out that there are so many definitions of reflection that another pair of researchers felt the need to subject them to metaanalysis.

Don't worry, though, because I've done the heavy lifting for you. For some reason, as yet undetermined, I read the whole damn article and learned that “reflection is more than just stopping to think and act based on what we already know.” It turns out that, while you and I have been in the trenches promoting health, waging war against disease, and trying to stay out of the lawyers' crosshairs, someone slipped another cornerstone into the foundation of medical education. It's called reflection, and it's sitting right next to that other newcomer, evidence-based decision making.

Now, I may be oversimplifying what Dr. Plack and Dr. Greenberg have to say, but it sounds as though all of us at every level of pediatric training and practice should be taking the time to think about what we've been doing, why we've been doing it, and whether it makes sense to keep doing it. It's hard to argue with their rationale, but there is that bothersome little piece about the time.

Stimulated by my plunge into the cold and deep waters of educational erudition, a few nights ago I found myself feet up, favorite locally brewed beverage within reach, considering how I would reinvent medical education. Who knows, I may have been reflecting. I even may have been epiphanating. Whatever you choose to call my condition, it's clear I shouldn't have been operating heavy machinery or seeing patients.

So here are my thoughts. I would mandate that all college students considering a career in medicine major in one of the humanities. History, art, music, religion—you get the picture. My decision to major in art history is one I have never regretted.

During the summer, these premeds must have a real job, preferably one in which they must interact with or serve the public, or work shoulder to shoulder with people who haven't and aren't planning to go to college. I am continually disappointed to learn how many young physicians don't really understand the everyday microeconomic challenges faced by their patients. I am also troubled by how many physicians don't have a clue about basic rules of customer service that could be learned by working for any successful shopkeeper or restaurateur.

Once these future physicians are in medical school, I would encourage them to shadow a wide variety of doctors from many specialties. As often as possible, these visits should include sharing an evening meal in the physicians' homes so that the student could get a more multidimensional picture of a physician's life. These glimpses can be valuable aids in both career modeling and pitfall avoidance.

After postgraduate training has begun, I would encourage new physicians to see as many patients as they can. Hidden in the commentary on reflection was at least one kernel of truth: “Experience is at the core of learning in medical education.” We can ask a student to read, discuss, and reflect on a single case of scarlet fever until the cows come home, but that student is going to be a much more effective clinician once he or she has had the opportunity to see so many scarlatiniform rashes that the sight diagnosis becomes second nature.

Freed from the diagnostic fumbling that comes with inexperience, students can spend their time and energy exploring the nuances of how individual patients deal with disease. Familiarity with the commonplace makes sorting out the unusual much easier, but experience means seeing 15 patients with scarlet fever, looking at 2,000 tympanic membranes, and listening to a dozen depressed teenagers tell their stories.

The problem is that we're back to that troubling piece about time. Sufficient time for physicians in training to see enough patients is in short supply these days, particularly if we have decided that it is important to protect them from sleep deprivation. Fatigue or experience? Now there's a dilemma worthy of some deep reflection.

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