Humiliation Based Learning

I still remember the day I learned I had been accepted into medical school and intense feeling of euphoria because I knew that I was essentially set for life. Once in medical school it is extremely hard not to graduate, once graduated after going thru some type of post-graduate training (for which you are paid) you are assured of being employed earning a comfortable and possibly lavish income for the rest of your working life. (Actually I was unemployed for weeks at a time as a family doc and in the early 1990s a number of anaesthesiologists I knew didn't have jobs).

For that privilege you have to put up with a few things, including student loans, long hours, hospital food and of course proving that you are actually learning something.

A general surgeon at our hospital preceptors medical students which means he takes them for several weeks, during which time they come to his office, his clinics, round on his patients and come to the OR with him. This is a heck of lot nicer than my surgical clerkship which largely consisted of dealing with problems on the ward and holding retractors. He is to be accurate not the only surgeon in our city who preceptors students.

He recently read the evaluation on his rotation by one of the students he had preceptored for a few weeks. This was a negative evaluation and the student accused him of "humiliation based learning". Seems our surgeon actually expected his students to read up on what they were seeing or going to see, to answer questions and if they didn't know something to read up on it. He would ask them questions during the day including in the operating room and the clinics where there were people like me and the nurses to listen. I heard him many a time and he was never disrespectful although he would remind the student that they had already talked about this.

This was of course how I and most of my generation of doctors learned things. We went around the wards with a clinician who would ask us questions in front of our peers and whoever else happened to be in earshot. If you didn't want to publicly humiliated, you learned to read up on your material. If the clinician knew that you were generally up on your stuff, he or she was a lot easier on you when you didn't know something. As you got higher up the food chain with more responsibility for patient care, the questions could become more pointed and the response to not knowing was often a reflection on your competency. There is no doubt some clinicians were bullies and targeted the weaker students/interns/residents.

Worse were the clinicians who played the "what am I thinking?" game. This involved a vague open ended question to which any answer you could give was not what the clinician was looking for. We had a number of clinicians like this in medical school. Sessions with them could be miserable.

Humiliating anybody is wrong. However we learned that if you knew the answer, if you at least appeared like you had read around the topic, if you had a reputation for usually knowing the answer or sometimes if you just said, "I don't know" instead of bull-shitting your could usually avoid the humiliation. The pendulum seems now to have swung too far.

When I was a resident, there was still the mantra, that a resident must be prepared to present on any topic at any time. We actually believed that and the first year of your residency was a terrifying game of catch up. The upside of this was that the last year of your residency when you had exams was less of a terrifying game of catch up. Due the CofE being on academic probation our little hospital is seeing more residents especially juniors and I am sometimes amazed (although less so now) but how little they have read, how they don't read journals at all and how a simple question like "tell me the anaesthetic implications of diabetes" (this is usually asked while we are doing a diabetic patient) sends them into a panic.

One of our gynaecologists informed me that they were told they shouldn't ask residents questions where the resident doesn't know the answer!

One likes to think that things like OSCEs, written exams and FITERs will weed out the unsuitables,knowledgeables and incompetents , however another doctor told me she is never going to fail a medical student again after having to take an unpaid day off work to attend the (successful) appeal. As a future consumer of the healthcare system, I am more than a little worried.

Only so much niceness to go around

I was explaining to somebody in the non-medical field about how much abuse we received as students, interns and residents from more senior doctors. (I didn't tell her how much abuse I still get as a senior doctor). She said something like, "But I thought all doctors had to be nice!". So I explained the facts of life to her.

Early on in my career I noticed that the doctors whose patients loved them all had one thing in common. Without exception they treated students, junior doctors, nurses and whoever else got in their way like shit. Now there were also doctors that were great to work with. Surprise, surprise they weren't popular with the patients. Some of them were actually not very nice to their patients which I thought was cool at the time.

I can remember doctors ranting, cursing, swearing in the hallway outside a patient's room usually at something I had done or often not done; rant finished we would go into the room and it would be "How are we today Mrs. Smith".

Fact is we all only have a finite supply of niceness which we can chose to spread around where we want. Unfortunately niceness is not something that can be divided, it is more a quantum amount; you can give it all in one direction or the other.

Another factor that has to be considered is the person's life outside of medicine. So you have three groups to be nice to: patients, co-workers and family. Most of us only have 2 quanta of niceness (some of us only have one). If you find a physician who is nice to both patients and staff, it is only a matter of time before he starts looking for cardboard boxes to move out. I had the pleasure of working with an internist who was both nice to patients and to staff. I was perplexed by this until I heard a couple of years later that he had just divorced his wife.