Teaching is Love

 From the 1/29/2021 newsletter 

 

Teaching is Love

 

 

Megan Schultz, MD, MA 

 

 

Dr. Schultz, who taught Spanish in an urban Baltimore high school before going into medicine, shares the story of the student who inspired her to become a doctor …

 

 

Before I was a doctor, I was a teacher. I taught Spanish at Frederick Douglass High School in Baltimore for two years before I decided to go to medical school. It was one of my students, Torreantoe Smalls, who inspired me to become a doctor. Torry was mischievous, with a quick grin. He played the trumpet like nobody’s business and tried, sweetly and patiently, to teach my clueless, clumsy feet how to step dance. He once got a B+ on a Spanish exam, and even though he was just beside himself with pride, he made me swear up and down I wouldn’t tell anyone he had had actually studied for it. During his senior year, Torry was shot multiple times in the abdomen during an attempted robbery. He would ultimately spend two years and three months of his life in the hospital, enduring dozens of surgeries and losing nearly two feet of bowel. It was in his hospital room, staring at his small frame in the bed, surrounded by the clicks and beeps of machines, that I resolved to be a doctor. 

 

Fifteen years later, here I am: a doctor, yes, but also still a teacher. Instead of high school students, now I teach medical students, residents, and fellows. Instead of teaching people how to speak Spanish, now I teach people how to be doctors. This is a tall order; sometimes it’s hard to know what to prioritize. When I was in medical school myself, I often felt impatient and restless, like none of my professors really understood the point of being a doctor at all. They talked way too much about things like the Henderson-Hasselbach equationand not nearly enough about how to save the life of someone like Torry. And the way they taught! PowerPoint slide after PowerPoint slide, crammed with text in tiny font that I was expected to regurgitate on command. I have often thought that medical school would be far more interesting and effective if it were taught by good teachers who know nothing about medicine as opposed to good doctors who know nothing about teaching. But how to be a good teacher for medical trainees? How to balance the need for basic physiologic knowledge with broad themes of compassion and empathy? I decided to ask the person who inspired me to be a doctor in the first place: I decided to call Torry.

 

Torry is not Torry anymore; he is Mr. Smalls. He is now a teacher himself; he teaches percussion at Mervo High School in Baltimore. He is also father to three children and runs an entertainment company called TORKO ENT. He still has the mischievous grin – but the speed at which it appears has been tempered a bit by age and wisdom. I asked Torry what makes a good teacher. His answer was arrestingly simple: love.

 

Torry described the importance of love by telling me the story of Mr. Burton, his music teacher at Douglass High. Torry had met Mr. Burton when he auditioned for the Douglass Marching Band as a skinny 8^th grader – and from the beginning, Mr. Burton believed in him and acted like a father figure to him. “He was the first person to see who I really was,” Torry says. After he was shot, Mr. Burton regularly visited Torry in the hospital. One of the days Mr. Burton was visiting, he was asked to step out so the nurses could give Torry a bath. (For months, Torry could not move his legs, stand, or walk. As a result, he had to rely on nurses for sponge baths in bed, which he describes as a singularly humiliating experience. “You know, I’m cool, so I don’t want nobody giving me a sponge bath. But I didn’t have NO choice!” he says with that old grin.) 

 

Torry said, “This was when I knew Mr. Burton loved me as a son… After my [bath], after my visitors came back in, I was sitting there in bed trying to lotion myself. And I was so mad that I couldn’t move my legs, that I couldn’t reach my feet. The man took the lotion – I didn’t even ask him – he just saw me struggling.” And Mr. Burton knew what to do. The memory of Mr. Burton empathizing with him in that moment, selflessly helping Torry with such a basic need, still moves Torry to tears fifteen years later. “He made me feel that I was loved,” Torry says. 

 

To love our students – it’s not often something we talk about as teachers. But maybe it is love that’s the foundation of any successful student-teacher connection: to believe in our students, to know what to do when they are struggling, to help them without being asked. Maybe if we start from a place of compassion and empathy, all the basic physiologic knowledge will follow.

 

Without Torry, I don’t know if I would be a doctor today. I certainly wouldn’t be the same type of doctor. All my students in Baltimore taught me far more than I ever taught them – Torry is the perfect example of that. There is such beauty in knowing that he is a teacher now, seeing his students for who they really are, believing in them, loving them. Torreantoe Smalls: once my student, always my teacher. 

 

 

Megan L. Schultz, MD MA is an Assistant Professor of Pediatrics (Emergency Medicine) at MCW. 

 

The Truth About Trust

 From the 10/2/2020 newsletter

Director's Corner

The Truth About Trust

Adina Kalet, MD, MPH

In this Director’s Corner, Dr. Kalet considers the importance and complexity of trust in medical education and encourages us to hone our judgement and have courage …

Anyone who doesn’t take truth seriously in small matters cannot be trusted with large ones either.

-Albert Einstein

The first presidential debate this week has me thinking about the consequences of not being able to trust someone on whom you depend. We rely on our elected officials, like our physicians, to listen, have empathy, engage in respectful - even if sometimes - heated disagreements, make good judgements in very complex situations, have control over intense emotions and, most importantly, consistently tell the truth. To “trust someone” implies that we have confidence in that person, and believe that the individual will be capable, adaptable, and competent now and in the future – even when faced with novel, rapidly evolving circumstances, emotional and physical stressors, and unpredictable challenges.

While always in the background, trust (“entrustment” and “trustworthiness”) has moved to the forefront in the medical education. How we make these trust judgements in medical education – and in life – is worth a hard look.

How do we measure trustworthiness in trainees?

Hodges and Lingard point out that the discourse about what makes a “good” physician – a core responsibility of our work as medical educators – has moved through a series of distinct and overlapping eras over the past seventy years. In the Psychometric Era, we valorized measurable, highly standardized knowledge tests (e.g. MCAT, USMLE Board Exams). The next phase brought great enthusiasm for demonstrable, directly observable, and behaviorally measurable core clinical skills (e.g. oral exams, mini-CEXs, OSCEs). Next, and to the frustration of many program directors, organizations introduced comprehensive, nuanced competency frameworks designed to capture and document each learner’s developmental progress via new standards and milestones.

These changes reflect our evolving grasp of “quality” in medical education. As our understanding improves, we will uncover how to develop rich portfolios of assessment data for each of our trainees. But in the end, data do not make high stakes decisions. We do. And these decisions require making trust judgements and having the courage to act on those judgements.

Trust judgement barriers and opportunities

Unfortunately, clinical faculty are not very good at assigning objective measures of competence. My colleagues and I spent years trying to get experienced clinicians to make reliable (reproducible) measurements of medical student clinical competence. Even with lots of fancy, performance dimension, frame-of- reference, and behavioral observation training, experienced professionals are eccentric and resist standardization. This, I believe, is because there is no single “truth” about clinical competence.

Trust judgments are highly context-dependent and idiosyncratic. We tend to be internally consistent and we know a trustworthy resident when we see one. An experienced professional possesses a highly-honed identity and a strong sense of what a trainee must demonstrate to be trusted to care for “our” patients. Unfortunately, we disagree with our colleagues on when individual trainees can be entrusted to “fly solo” and more independently care for patients. Gingerich has challenged us to embrace this disagreement and see it as a strength rather than a weakness.

Furthermore, experts are also context-dependent! As we collect and collate more-and-more data from larger, diverse pools of experts, we must ensure that trust judgements are appropriately interpreted to protect students from the vagaries of any individual’s bias. This is what van der Vleuten and others call a Program of Assessment for Learning. Ultimately, trained competence“judges” will be charged with making final high stakes assessments regarding decisions such as advancement and graduation. These judges will determine if, based on solid evidence, we can trust a learner to consistently “do the right thing, at the right time, for the right person, and for the right reason” in their next phase of training.

Moving from theory to action

Social and cognitive psychology researchers suggest that competency judges need to both understand the value and limits of the objective data (e.g., exam scores don’t predict clinical skills competence, but they do predict future exam scores) and should explore and develop their judgement “sense.” This sense of who to trust is highly dependent on an individual’s characteristics, experiences and biases. Knowing thyself, in particular understanding one’s biases, is crucialbecause if we are cognizant of them and have integrity, we can make adjustments – “forcing” ourselves to slow down our thinking, toggle to a more analytical rather than intuitive deliberative strategy, when we are in danger of making an error. This takes work, discipline, and practice with feedback.

There is much interesting work to be done to ensure we have trustworthy physicians. Fundamentally, most of us make our trust judgements based not on what students know or can do (we can always teach that stuff), but on who they are as people. Do they always tell the truth even when it leaves them in a “bad light?” Do they admit when they missed a physical exam finding or forgot to check a lab or failed to follow up on something? Do they take the time to listen, attend to details, interact with empathy and kindness, even when stressed emotionally? Do they strive to improve rather than rest on their laurels or test scores? Do they seek to understand the perspectives of others? How do they handle being wrong or making a mistake? Can they sincerely apologize?

We are accountable to society to make defensible promotion and graduation decisions based on each learner’s competence and trustworthiness. These are difficult-to-measure, shifting concepts. We pledge to engage in the ongoing discourses and learn how best to make difficult, discerning judgements.

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.