In trying to answer the fundamental question: “What is it that makes a good teacher in medicine?” we should consider the context in which the teacher nowadays performs his role as an educator.
Let us try to briefly outline the image of medicine in society:
- A rapid succession of scientific discoveries which are clearly important but which often express medicine as becoming always more technological, hence obscuring its human dimension based on relationships,
- The criticisms and almost daily polemics resulting from cases of malpractice that demand from us a change in the way medicine is practiced by some persons but at the same time obscures the commitment and the dedication of many good professionals,
- The constraints of a health system in which the doctor may feel deprived of his role in order to obey rigid economic and organisational criteria.
One could ask whether young people still want to want to take up this profession. Yet if we observe the numbers of applications for entry into the biomedical faculties, we could conclude that the numbers of those who would like to take up education in this field are very high.
Recently there has been some discussion as to whether the selection tests are still valid since they do not look into attitudes and motivations, but prefer a knowledge of notions that is isolated from the preceding educational process.
If this is true, then the academic process should be able to verify the potentials within each student and develop those personal characteristics necessary for the caring profession.
It is known that the current curricula of biomedical faculties may often have the effect of dehumanising the students and transforming their idealism into cynicism.
Very frequently, there is a lack of explicit attention given to the values of humanism and of authentic professionalism. This creates a learning environment diametrically opposed to good medical care.
The ways in which the trainees are treated and the values that are transmitted by their teachers and by the institutions exert a great influence on the way in which in their turn the students will treat their patients, themselves and the others.
Unfortunately, certain aspects of the educational process may provoke negative consequences on the global health of the students. Some research has found that medical students have a high incidence of personal discomfort with potential repercussions on academic performance , competence, professionalism, and health (academic dishonesty, cynicism, substance abuse, suicide).
At a time when the universities prefer to be well known for their research rather than for their education, we run the risk of scientific inbreeding of a new generation of professionals who will not be satisfied nor emotionally competent to give the daily clinical care that is the basis of medicine.
Abraham Flexner, about a hundred years ago, had published a report about the fundamental reforms in the medical education of the United States. Years later we were worried that the pendulum had swung too far towards science, distancing itself from the humanistic aspects of medicine. To obtain the exact “chemistry” for the future generations, he hoped that a more holistic approach would be developed, more sophisticated in selection, based on factors that would predict the ability to care, that was closer to the needs and expectations of the patients.
On the other hand, it has also been said that speaking about the roles and duties of teachers in the formation of students is a little like talking about the history of art starting from paint brushes. What objectives should be made by the teacher? And before this what are the qualities that a teacher should have? It has also been said that the most precious possession of any university is in the teachers who are defined as being “inspired” or even “illuminated spirits”. These are persons who possess something difficult to define which evokes interest and enthusiasm from the students. But these persons are so rare in all biomedical faculties. How few are the teachers with the ability to leave a mark in the memory of their students. And how really appreciated they are by the students themselves.
Doctors who dedicate themselves to medical education in one way or another, usually do so out of their own free will and with passion, even though their own preparation for this role may not be full. Often they owe this bravery on the field essentially to their experience and their intuition, and not to any type of formal preparation.
In what way is it possible to fill this gap between formal preparation and the performance of a teacher. One method is to consider the process of apprenticeship as a basic human experience and teaching as a form of interpersonal relationship (based on the involvement of the teacher and his desire of making himself useful to his students). Therefore, as everyone has his own style of forming interpersonal relationships, the style of teaching will not be limited to a few stereotypic methods, but each one would behave in his own style: this would also depend on the student he has in front of him… on his needs and priorities….
Excellence in the field of education is the fruit of more than one factor, but probably the most important is a sincere and profound interest in helping the students in the process of learning.
Today information can be obtained from journals, textbooks, CD etc. the role of the teacher is not so much that of expanding notions, at the risk of poor relevance to the clinical context, but of making the practice of the profession understandable and rich in significance. Rather than give data, he is called to “form”, to furnish that extra element , which goes beyond what is normally given in textbooks, in order to promote clinical reasoning and the professional development of the student.
One talks very much of the importance of mentoring in academic education. It is noted that the figure of the mentor is inspired by Greek mythology; when Ulisses left for the war in Troy, Athena goddess of wisdom, presented herself as Mentor, who was a trusted friend that assumed the responsibility of the son of Ulisses, Telemaco. Mentor was not only his teacher, but also a determining presence during his growth and development from infancy to adulthood.
The figure of the teacher in his role as mentor therefore requires an important involvement and this is understood because it has been amply recognised as a determinate ingredient for success in medical education: it can potentiate the implied knowledge in the so called “hidden curriculum” of professionality, of ethics, of values and the art of Medicine, all elements that one cannot learn from texts. Moreover it can be of emotional support and encouragement. At the same time this relationship is advantageous even to the teacher, inducing a greater productivity, satisfaction and personal gratification.
Certainly, in order to maximise the quality and the fruit of such relationships one assumes an awareness of self, attention, reciprocal respect, and authentic communication.
An interaction supported by these characteristics has been revealed as a potent means of learning and of changing inadequate behaviour, of re-evaluating protocols, focussing them on the individual patient.
Even in education one emphasises the importance of practice: it is not sufficient to have in front of one good professionals to learn. Each student should not only experience the different techniques, but experiment with different ways in how to relate to patients. Already in some universities, even in Italy, students in the first year have begun to visit the wards, not to work or learn techniques, but to be educated in human contact with patients, therefore independently of health practices. In this way the youths understand the need of patients in their human dimension, with all their baggage of problems and suffering.
On the other hand, one emphasises that one learns 10% of what is read, 20% of what is listened to, 30 % of what is seen, 50% of what is seen and heard, 80% of what is said, 90% of what is done. And all this occurs with a synergic effect.
Moreover, one brings to light in this manner the humanistic aspect of Medicine, which one may define as medical humanities, in an effort at integrating scientific knowledge with a humanistic approach, experiencing illness in the context of the personal history of each single patient.
The real interest in the well-being of patients however cannot be learnt but from example.
And this is confirmed, in the negative, even from recent research: the main obstacle in education has been revealed as the nonprofessional behaviour of educators, at times “protected” by a hierarchy of academic authority.
An efficient way of teaching how to understand the needs of patients, demands from the teacher first and foremost a demonstration of sensitivity towards the needs of their students, according to the rule: Treat your students just as you would want them to treat their patients…. If then the students realise that the teacher is behaving in this way with his patients, the lesson may be considered complete. A good teacher cannot reduce himself to just technical aspects: it all depends on his personality and his integrity.
But even correction may be considered to be an important aspect of the educational process: accepting to correct one’s own mode of work can be a motive of growth and improvement even in the professional field. I have experienced however that the most satisfying result is achieved if the criticism is done sincerely in order to help the student, in the proper way ( not because on that day we woke up in a poor mood and taken our problems to work). Therefore it will also have the effect of strengthening the relationship between teacher and student . And equally one must not be sparing in praise and encouragement…
Medicine today demands a new challenge. Maybe it is no longer the time for the teacher who on his own founds a “school”, so to say, almost a person with a “charism” as used to happen in the past. The complexity resulting from the technologies applied to medicine and from the knowledge and discoveries that are ever so rapid, necessarily demands a new competence and a new ability of knowing how to work together, an ability that cannot be improvised or taken foregranted.
Today one emphasises more than ever treatment as a team, the multidisciplinary approach. But are we being educated in this as students or teachers?
The educational process is often still addressed towards an autonomous development of the profession: consequently in the different places of health care, at times one sees individualism, the defence of one’s own role, the ambition of a career even at the expense of other colleagues.
And it is not enough to try and integrate in the same place of work to create a team: it is more necessary that not only the teachers and tutors but all the persons involved work actively towards this. And even patients will see this, with undoubtedly great advantages on their treatment and on the climate of relationships.
How important is the relationship with patients: often we realise that we receive more than we give. How I have myself experienced- but everyone can repeat the same thing – my professional life is all woven out of many significant moments in which I have felt “edified”, at times “strenghtened” through an experience lived with a patient, through the sharing of moments of suspense, of suffering, of new hope, that are enriched humanly and that help emphasise the essential aspects not only of the profession but of our own existence.
And all this may translated into the relationship between the teacher and the student: just as the teacher can instil enthusiasm, passion, help discover motivations, in the same way he can receive just as much, and therefore a relationship of reciprocity is created. The student can stimulate the teacher to keep himself updated in the clinical and scientific aspects, so that he would be able to answer questions, but even to perform better in the ethical-deontological aspect. Idealism can become obscured with time, with work which is often consuming. Many times I have been asked to intervene by the students or by the young professionals themselves, who find themselves in a crisis because of incorrect behaviour or simply because the teachers take foregranted some practices which are not transparent…
It is evident that that one requires energy, motivation, determination to face difficulties outside and inside oneself, in order to find the way of overcoming them.
We all find ourselves, students, teachers, specialist trainees etc, inside systems – academic, health care, institutional – that at times seem to be centred on the structure, more than on the persons involved for whom the same structure has been created. It may seem impossible to act to change various organisations. But it is good to remember that these systems are formed of persons.
If we want to give a contribution towards possible change, one first step may be to build dialogue with the persons involved: the individuals irrespective of the role each one occupies. It may not seem so simple nor so easy to accomplish…
Certainly the step of emerging from oneself in order to live the other person, to share his difficulties, to learn his expectations, brings about unexpected potential, it can generate a relationship that “goes and comes back”. And often it is this “return” that helps re-aquire serenity, re-discover our sense of behaviour, discover possible answers. In this way there is a leap in quality: reciprocity can transform every component of the world of health care – carer or patient – every component of the academic world – student or teacher – as subject, protagonist of change.
In effect it has been affirmed that “hope is not believing that things change, hope is believing that you can make a difference”.
Flavia Caretta
Catholic University of the Sacred Heart
Faculty of Medicine and Surgery “A. Gemelli” – Rome
