25 October 2008

Sherlock Holmes

Dr Grumble's latest batch of medical students are very green. Very bright but no knowledge. Everything clinical is new to them. It's rewarding to teach bright students who know very little. The less they know the more you can teach them. It's like starting with a blank canvass and painting a masterpiece. Maddeningly Dr Grumble has his students for only a month. It's crazy, of course, but nobody listens to Grumble. He used to have them for eight weeks. In that short time if students and Grumble worked hard the rudiments of history taking and examination could be taught. The beginnings of a masterpiece could be created. Some of these students will end up much greater and more important than Grumble. Amongst them may even be the Lord Darzis of the future. And, hopefully, some really good GPs.

The job of teaching is important but there's little reward. Nobody in the hospital hierarchy really cares about how well you do your teaching. They say they do but they don't. Small group teaching is essential when it comes to clinical work but only the small group even knows you have done it. These days they report back online on the quality of the teaching. But sometimes they do not quite know how good their teaching has been. They do not know that the notes they write will forever be better structured than the notes of those who were not taught properly. They do not know know how those difficult questions were not to make them look stupid or to check their factual knowledge but to get them thinking in the right way to be a decent doctor. They do not know what they don't know, what they really need to know and where they are heading.

Eventually Grumble's students do realise what he was trying to do. Sometimes anyway. Just occasionally Dr G will get an email from a student or doctor thanking him for teaching that took place years earlier. Sometimes in these emails they explain that it was only later they came to realise the importance of the Grumble style of bedside teaching. This is Grumble's only reward. It's his greatest reward. It's the only reward he wants. Dr Grumble had teachers he appreciated, teachers he wanted to emulate. He hopes he thanked them.

Some years ago Grumble used to teach Japanese medical students. Don't ask why. Even Grumble does not know. They just turned up and Dr Grumble just taught them. He used to ask them who wrote Sherlock Holmes. They always knew. The home-grown students can look bewildered if you ask them a question like that. They certainly don't see its relevance. But it is relevant. In a way. Because the next question is about how Sir Arthur Conan Doyle got the idea for Sherlock Holmes. And the answer, which they rarely know, is from Dr Bell who used to teach Sir Arthur when he was a medical student. Dr Bell, like all physicians, was a detective. Sometimes he could tell what parts of the world his patients had visited and what jobs they were in. Dr Grumble can do some of this. It impresses students no end.

The other day Dr Grumble met a patient for the first time and told his students in front of the patient that he thought he had been in the army, that he had worked in the past as a coal miner and that the had given up smoking about six weeks ago. The patient dutifully confirmed all this. The students were visibly impressed. Dr Grumble thought that from then on they would be taking him seriously.

How did Dr Grumble do this? It isn't that difficult. Patients who call the doctor 'sir' have usually been in the armed forces, coal tattoos in old cuts are common in previous coal miners and if fingernails grow at 3mm a month it is easy to work out from the tar staining when the patient stopped smoking. Now doesn't that sound like Sherlock Holmes explaining his deductions to Watson? It's easy to see how medicine lay the foundations not only to a series of good books but also to modern detective work. As Sir Arthur says himself in the only surviving recording of his voice. The recording is a bit stilted and there is only a hint of the admiration and gratitude Sir Arthur showed for his teacher, Dr Bell, without whom there may never have been a Sherlock Holmes.


Anonymous said...

When I trained (only graduated this year, mind) we had very little, if any, "traditional" bedside and small-group teaching. When it did occur, it was by far the most valuable and informative education I had.

Sadly, teaching ward rounds and taught examination at the bedside seem to have been replaced, at least in some places, with large lectures (even in the clinical years) with fewer (or no) questions to the students, and a shift from the gaining of knowledge to the production of essays and reflective nonsense which do not teach you anything about the practical conduct of medicine.

I will not name the medical school involved, but I have calculated that I produced 25-30,000 words of essays and "reflection" in my busiest clinical year. Having handed everything in, I then crammed for my written finals and passed, with a B, after a week's study! I'm not sure that the latter should be achieveable for someone like me, who, was a pretty average medical student, and wonder if the exams have been dumbed down to compensate for the reduction in teaching.

I think that there has been a shift away from the acquisition of knowledge and practical experience to the thinking that it can all be learnt from books and writing, and I feel that I am worse off as a doctor because of it - I now work as an FY1 with an average graduate from a more traditional medical school and, at least to me, the gap in knowledge and in thinking the right way is clearly noticeable.

Anonymous said...

I am at one of the more "traditional" medical schools, and even there, we have real difficulty getting taught.

I am in my first year of clinics (3/5 years) and admittedly my experiences have been skewed by starting out on a surgical firm - result being that I saw my consultant once a week in his clinic where I got some decent teaching, then spent the rest of my time following the FY1s around (the consultants and registrars all went off to theatre, the SHO was on nights most of the time), so essentially was taught most by people who were only 3 years older than me. I won't say it wasn't useful - they knew how to examine and clerk patients, and were patient enough to let me present to them ad nauseam, but when I had to get an assessment filled in by someone above SHO level you wouldn't believe the difficulty I had tracking someone down who was prepared to spend 10 minutes listening to me.

My experience is by no means uncommon - other rotations don't make you come in for ward rounds, some don't allow you to take blood, and one hospital won't let student stay past about 8pm (bad luck if you wanted to stay to watch a really interesting surgery),
but it is clear that a common theme is that registrars and consultants are not all that interested in teaching. I don't blame them at all - I can't imagine the pressure that they are under - they certainly work hard to make up for lack of staff.

This has been a pretty rambling post, and I guess the core argument I'm trying to make is that we need clinicians who are up to date and competent, but who also have the time and energy to teach students. Perhaps the creation of a half-half clinician and teacher post would solve some of these problems?

Thanks for writing this blog, Dr. Grumble - your students are very lucky to be taught by you.

Meckel said...

I'm a second year SHO and I really enjoy teaching medical students. The medical school attached to my hospital is not the one I trained it and it is a great lover of log books and ridiculous acronyms. It's sad to see students aho only want to present "Presenting Complaint" and "Social History" and "Respiratory Exam" because that is what their log book tells them they should be doing on Week 2 Day 4.

I was lucky enough to go to a very traditional medical school where the emphasis was on repeated and throrough history taking and physical exam and being grateful for the chance to present to anyone; intern to Consultant. Some of the best teaching I received was from the most junior of doctors and in retrospect I can appreciate how gracious they were to incorporate teaching medical students into their busy day.

Daniel Smith said...

Re "These days they report back online on the quality of the teaching."

I am involved in this kind of activity

see http://reports.pmetb.org.uk

I read your blog with interest, as I'd like to be able to identify where good teaching occures. If you or others have suggestions for questions that would help with this. I'd be interested in hearing from them

Daniel Smith Head of Surveys