~:
Medical Education
The tradition of great teachers in medicine is flagging. By Richard M. Ratzan, M.D., '67
I
16
often muse about great teachers and history. I wonder, for example, about smallpox and Parkinson's disease, and about what would have happened if one of John Hunter's assistants, instead of the master himself, had performed the pedagogic chore (as it is looked on nowadays) of teaching Edward Jenner or James Parkinson. Would the inspiration that these two men received have been the same? Probably not. If they had known beforehand that they would see Hunter rarely if ever outside his laboratory, would they still have come? Again, probably not. For students flocked from far and wide to Hunter's side, as they did to Socrates and Peter, to be taught by a renowned teacher. They did not flock to be taught by "postdocs." Yet the tradition of proxy teaching in medicine (like that of proxy refereeing for journals) seems more firmly entrenched than ever. Great clinicians and scientists now follow the curs us doctorum of being a junior teacher-investigator initally teaching all comers, then a full-time investigator teaching primarily fellows, then an administrator teaching no one. The irony of having a clinician or scientist at the peak of his or her wisdom spend the least time with the students who need such wisdom the most cannot fail to impress even the most casual student of students and their teachers. Such a phenomenon reflects a system with its priorities on backwards. The reasons for this historical reversal since John Hunter's day are easily discerned. First and probably foremost is the failure of teachers to perceive the teaching of medical students and house staff as exciting and worthwhile work. Who, they might ask, would want to explain, for the 50th time, the distribution of body water or diuretic-induced prerenal azotemia to an intern when one could be planning a research project on the effect of antidiuretic hormone in microtubules with a fellow over coffee and Danish? Teaching medical students and house officers is, to be sure, repetitive, often unstimulating, and hard. Such teaching involves groundwork, the laying down of tracks and ties. It is certainly taxing to make clear to a freshman what is old hat to a third-year fellow . Teaching students at an early stage is, as Joel Hildebrand has observed, "more of a challenge ... and more of an art to do it well."' The modern emphasis on research, especially bigtime research on basic (non-patient) materials, must also receive some of the blame. Teacher-investigators are usually hired to be investigator-teachers. What department chief, dean, or promotions and tenure committee researches the teaching credentials of a prospective researcher? It matters little to universities that a less
extensively published and cited researcher happens to be an excellent teacher. The candidate with more listings in Science Citations Index will get the job every time. Teaching, consequently, gets tacked on as an added responsibility and an implicit onus - i.e., the dues one must pay the system. The researcher must then maintain the schizophrenic posturing of an investigator fighting for his or her academic life by getting grants and publishing while perfunctorily putting in teaching time or, better, figuring out how to allocate it to postdoctoral teachers. For many such investigators, a minute in the classroom is perceived as costing an hour in the laboratory. To even more, the minute feels like two hours. The superior worth accorded research has displaced, along with the teaching responsibility itself, the raison d'etre of teacher-investigators in a university setting. "Publish or perish" is truer now than ever and almost demands a minimum of classroom time, especially when the amphitheater chairs or bedsides have mere students for an audience. Robert Nisbet has bemoaned this trend in Masters, recalling that "in the Berkeley of the 1930s, and other universities also, such [beginning] courses were not held to be demeaning, and the status of a scholar or scientist was not measured by the degree of his liberation from contact with undergraduates." 2 How many readers today would recognize the identity of the speaker reflecting in 1892 on his career as a teacher, the "best years of whose life have been passed with undergraduate students, and who has had temporarily to content himself with the dry husks of graduate teaching"? 3 A third explanation for the diminished role of established teacher-investigators today is the medical tradition of "see one, do one, teach one." This instant license to teach is used too often as an excuse by many a professor to allow the residents and fellows to do some of the teaching that the professor should really be do-