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"You're the worst medical student I've ever met"

You can be a stickler for details, but don't throw out compassion and creativity, says this physician.

By Noah R. Gilson, MD
Neurologist/West Long Branch, NJ

"You're the worst medical student I've ever met."

I had just started my clinical rotations in 1980 when my instructor, a senior resident in internal medicine, gave me this blunt appraisal. My crime? I had asked a "stupid question" about something that, according to my critic, I should have looked up myself.

The instructor—I'll call him Bob Daniels—was an unsmiling despot with a Napoleon complex and a teaching style straight out of the Inquisition. His method was to interrogate medical students, usually without warning. The sole purpose of these exercises, it seemed, was to demonstrate how little we knew. He said he was trying to motivate us. Mainly what he did was demoralize us. He nearly chased me out of medicine.

For most of the past 20 years, I've taught medical students myself, vowing to do a better job than Bob Daniels. Based on my experience, I've come up with a few guidelines for mentoring tomorrow's doctors. It's a responsibility many of us have, whether we work at a teaching hospital, have medical students rotate through our office, or simply see them while we're rounding.

Never teach by shame. I try to follow the tenet that if I don't like being humiliated, then I should never humiliate somebody else. Abused students can become abusive doctors. And another generation of doctors perceived as arrogant and dictatorial by patients is the last thing our profession needs.

Be positive. In addition to Bob Daniels, I've had teachers who were warm and caring human beings. They educated not through intimidation, but inspiration. They exuded positive attitudes about medicine and tended to complain less about "we poor doctors" in the hospital cafeteria. For them, being a doctor was a calling, not just a job.

Make learning fun. I try to emulate a medical school instructor named D. J. Hennessy. He was a wry, impish little man doing a fellowship in infectious disease, and the love he had for his specialty was infectious, too. He once said that he pitied us because we only had six weeks to learn about his specialty, whereas he had an entire career to do so. "So let's not waste a moment!" he'd say. "Let's get started." He questioned us non-stop and gave prizes like free lunches and candy to students who answered correctly. He might as well have been hosting a TV quiz show. None of us wanted the rotation to end.

Focus on the basics. I tell students that we should never lose sight of why we are doctors. We are trying to help real people with real diseases. It could be your mother. Or it could be you. I recount my experience of undergoing neurosurgery for a meningioma. Suddenly I had a completely different perspective on this doctoring business. I recall how it felt when the chief neurosurgical resident asked me if I was "the meningioma in room 404" and how I replied, "No, I'm Noah Gilson. Who the hell are you?"

Exhibit a good bedside manner. I can teach my students a lot with the body language I show patients. I learned much of this from an internist I'll call Jack Fisher. At first glance, he appeared to be the least likely person to have a good bedside manner. At 6 foot 6 inches and 280 pounds, Jack still looked as imposing as he did when he flattened opponents on the gridiron at the University of Notre Dame. His size, though, belied his gentle manner. He took the time to listen to patients, answer their questions, and impart a reassuring touch with those big hands of his. Jack was careful not to be too invasive in his questions or physical examination. Aware of a patient's vulnerability, he seemed to be asking permission to probe as deeply as was required—but no deeper.

Value your students' comments. Yes, we can learn from medical students. Sometimes they have information that we lack, often because they're more computer literate. My students frequently have directed me to useful Web sites that helped us care for our patients. By dropping the patronizing attitude and actually using the information presented by students, I make them part of the management team.

Initiate your students into the "fraternal order." I make it clear that physicians belong to an ancient guild. We take oaths committing ourselves to high standards of conduct and specific obligations to our patients. Sometimes we have no choice but to run to the ED at 3 a.m. or answer the 37th call from Mrs. Jones about her migraines. I teach them to do this cheerfully and enthusiastically. After all, nobody forced us to become physicians.

I also remind students that they must be completely honest in reporting findings. This may require admitting that "WNL" means not "within normal limits," but "we never looked."

Uphold the patient's dignity. I never refer to patients as gomers, frequent fliers, dirt bags, or other pejorative terms that doctors sometimes use. I insist that students adhere to respectful speech and common civility. It's not courteous, for example, to interrupt a patient's breakfast so we can examine him at our convenience.

Teach students to be compulsive. I tell students that intelligence is only a small part of being a good doctor. What counts the most is the relentless and compulsive pursuit of the tiniest details. This attentiveness can be the difference between making the diagnosis and blowing it. Sometimes it's the difference between life and death.

Teach students to trust their judgment. I favor the "total immersion" method of teaching. I send the student out to learn as much as he can about the patient, using the history and physical as an outline for information gathering. When he presents the case, I ask a series of questions. What did the patient say and what did he show you? Did you pick up on nonverbal clues? Did you have a full understanding of his cultural context? And finally, what do you think is going on? What did your gut say about this patient? What other information do you need from the patient, the family, the labs, diagnostic studies, or from your reading to either substantiate or to rule out your clinical impression?

This sort of learning, though it may initially terrorize novices, is powerful. The more the student knows, the more confident he becomes in making diagnoses. So aim at cultivating confident doctors, even if it means they have to spend hours in the library seeking information.

Preach humility. Whenever I feel myself getting pompous, I think of how much I don't know. I encourage students to do the same. As an exercise, I tell them to think of physicians in the Middle Ages who spoke with absolute authority about "good and bad humors" and the value of bloodletting for all ills. Perhaps this is how we will sound to doctors in 2100.

Likewise, I tell students that it's okay to say, "I don't know, but I will try to find out." We don't understand everything about human disease. In fact, we're not even close. So we must keep reading and studying. I show students through my own pursuit of continuing medical education that learning is a lifelong endeavor.

Be yourself. Finally, present yourself to students as the person and physician you really are. Don't become some preconceived notion of what a physician teacher should be. Be flexible and innovative. Do whatever it takes to get your point across. Have fun. Relax. And remember that you have only one goal: To pass on your noble profession to the next generation. Good luck!

Noah Gilson. "You're the worst medical student I've ever met".

Medical Economics

Aug. 22, 2003;80.