Book Review

Teaching Medicine: Process, habits, and actions

N Engl J Med 2000; 342:1058-1059April 6, 2000

Article

Teaching Medicine: Process, habits, and actions
By J. Willis Hurst. 197 pp. 1462 Clifton Road NE, Suite 301, Atlanta, GA 30322.

This slim book contains the reflections on medical education and training of a well-known presence in American medicine and medical education, J. Willis Hurst. The major topics he discusses are clinical teaching, the organization of curriculums, and the problem-oriented record. The book does not pretend to be a review of the literature on these themes, since nearly all the references at the end of each chapter are to Hurst's earlier writings. Yet given his substantial contributions to clinical medicine and medical education (154 Medline citations from 1966 to the present, several books, numerous chapters, and an unknown number of trainees and physicians influenced by reading his work or by seeing him examine a patient or teach), his views are worthy of our attention.

Hurst was trained at Harvard Medical School and Massachusetts General Hospital under Paul Dudley White. He joined the faculty of medicine at Emory University in 1950 and served as professor and department chair from 1957 to 1986. That tenure as department head is astonishing (to me, at least) by current standards and testifies not only to Hurst's energy and character but also to how much the world of medicine has changed since he retired. Hurst reviews some of the changes and, for the most part, feels that things were better in the past. He laments the declines in a number of areas.

The first is that ward rounds are no longer teaching rounds in some hospitals. Attending physicians blame managed care for eating up the time they would like to spend teaching. What can be done about this? Hurst is silent.

The second area of decline is medical grand rounds, which used to be formal case presentations. This was the desirable format, because doctors remember facts and principles that are linked to patients, especially their own patients, more easily than facts disconnected from their own experience. Now, increasingly, medical grand rounds have become lectures that are nearly always ineffective and are soon forgotten. Why has this happened? And what can be done to restore the classic format? Hurst does not say.

The third decline concerns visiting professors. Visiting professors used to be chosen by the department chair or division head, and they would visit a school for three or four days. During this time, there were ample opportunities for trainees to meet and talk with the distinguished visitors, who also conducted separate teaching sessions with medical students, house staff, and fellows. “The impact of the visit on the local group was enormous.” Now, visiting professors are sponsored by pharmaceutical companies; the visitors meet rarely with students, house officers, and fellows. Instead, they give a lecture on a subject of their interest, which “`coincidentally' matches the interest of the pharmaceutical house” sponsoring the visit. The agenda of the visitors is increasingly not about teaching, and this trend should be halted “as quickly as possible.” But how? Hurst offers no suggestions.

The fourth decline is in the area of consultations. Because hospital stays have been shortened so drastically, surgeons no longer have the time to ask a consulting internist whether it is wise to perform a particular operation. The consultant instead is asked to deal with postoperative complications. It is more difficult for patients to obtain a second opinion than it was in the past.

The fifth area of decline is board examinations. Formerly, a written examination tested a candidate's knowledge, and an oral examination tested his or her clinical skill. Now, clinical skills are no longer examined. The examination sends the wrong signal: it tests short-term factual recall and not clinical skills, including skill in thinking.

Finally, Hurst laments that the clinical skills of house officers have declined. “The dismal state of affairs is not the trainee's fault.” As before, trainees continue to be highly intelligent and motivated people. So what has happened? Once again, the blame lies with managed care: it restricts the time a physician can spend with both patients and students, and teaching and caring for patients both take time.

The chief solution proposed by Hurst to all these problems is better teaching. Above all, medical education needs more “true teachers,” a term Hurst uses to refer to teachers dedicated to becoming intellectually engaged with their students, not telling them the answers but asking questions that cause them to think about the causes of disease manifestations, and seriously fostering the development of their clinical skills. The need for this type of teaching has long been recognized. It has been part of the Western educational canon since Plato wrote about Socrates in Athens. Hurst recognizes that acquiring clinical skills takes time, practice, and skilled, timely feedback. But the larg-er problem is, what is happening in the health care sys-tem that aggravates these problems? Hurst points to managed care, shortened hospital stays, and similar constraints on daily sustained contact between mentor and learner, but regrettably, he does not propose solutions to these problems.

Like many physicians of his generation, Hurst recognizes that something has been lost in American medical education in the past 10 to 15 years, and he does not know how to recapture it. To some extent, admittedly, these feelings are typical of senior citizens — things were better in the past. But Hurst is not alone in feeling that despite the technological wizardry now in abundance in American hospitals, thinking and caring physicians either are in short supply or must practice their art under constraints that lower the level of care. On this melancholy note, he leaves us with a great deal to think about.

Arthur S. Elstein, Ph.D.
University of Illinois College of Medicine, Chicago, IL 60612-7309