Elnicki, D. Michael MD
Dr. Elnicki is professor and chief, Section of General Internal Medicine, UPMC Shadyside, University of Pittsburgh, Pittsburgh, Pennsylvania.
Correspondence should be addressed to Dr. Elnicki, Department of Medicine, UPMC Shadyside, 5230 Centre Avenue, Pittsburgh, PA 15232; e-mail: firstname.lastname@example.org.
The accompanying piece describes using emotional manipulation to heighten students' absorption of lecture material.1 The theory is that emotions can focus learners and enhance learning. However, we should remember the word “emotion” comes from the Latin “emovere,” which means “to move away.” Although positive experiences may engender learning, negative emotions can lead to withdrawal and removal as much as retention of information.
Before we accept Taylor's hypothesis, we should ask ourselves several questions: (1) Does this assertion fit with prior educational research? (2) Would this be generalizable to other teachers and situations? (3) Is there a level at which stress is good? (4) What greater lessons do we want to teach beyond the content of a lecture?
At the level of educational theory, this approach seems contrary to the principles of adult learning theory. In The Adult Learner, Knowles et al2 remind us that significant learning can be a threatening experience during which the learner is vulnerable. The instructor should create an environment that is comfortable, “both physically and psychologically.” In contrast, Taylor describes her learners as “instantly and profoundly distraught.” As Skeff3 demonstrated, learning climate is a critical component of effective teaching. Skeff3 defined learning climate as the “tone or atmosphere of the learning environment” reflecting “the degree of stimulation, enthusiasm, comfort and excitement generated by the teaching process.” Clearly, emotions are involved, but Skeff goes on to describe the teacher's enthusiasm and the learners' comfort as major concerns. Learning medicine is already stressful, and raising the level further hardly seems desirable.
Taylor's director of curriculum affairs remarked that “you could get away with” using emotion in teaching, implying that, for many educators, there could be adverse effects to such a technique. Before trying to generalize this technique, educators would need to feel comfortable enough with their relationship to students to think that manipulating them emotionally would be worth the risk of damaging that relationship. We know that our students learn in many different styles, and it may be that some benefit while others will suffer from this approach. Students' stress levels fluctuate, and we should take care not to place the “straw that broke the camel's back.” We can all remember long hours, fatigue, and multiple admissions where service duties rather than learning became the goal. At some point, stress becomes overwhelming and counterproductive. That point is variable and difficult to predict.
A great deal of research shows that the mistreatment of medical students can have profoundly negative consequences, including depression, substance abuse, changing career direction, and leaving medicine entirely.4 As Ogden et al5 described it, abuse consists of “policies, speech, actions or behaviors that treat a student in a threatening, intimidating or otherwise inappropriate manner sufficient to affect the student's learning environment.” I would not characterize the act described by Taylor as abusive, but it could easily be extended and could shift the learning environment in a deleterious direction.
As clinician–educators we would never provide false information to our patients, as the potential negative consequences are obvious. Much of clinical teaching takes place through role modeling, where we model professional attitudes and behaviors. Role models can have profound effects on students' learning experiences and subsequent careers. Good role models in clinical medicine stress the importance of the doctor–patient relationship and psychosocial aspects of medicine. As teachers of medicine, we need to be aware that we serve as constant role models for our learners, and we need to act accordingly. We want trainees to learn a humanistic approach to medicine. In a study of effective medical student teaching, much of the variability in effectiveness among instructors was explained by a model that contained “treating students with respect” and “providing a role model” as two independent variables. The model was independent of academic rank, gender, or specialty of the preceptor.6 These findings indicate a degree of generalizability in how we should interact with our learners.
Students of medicine will experience many kinds of stress. They will work long hours and will endure intense experiences, including seeing patients die. As instructors, we don't know what students have recently seen on clinical rotations, and we don't know what is happening in their personal lives. Every year, a few students will unravel emotionally from the stress. As instructors, we are seldom aware of individual students' stress levels and who is “on the edge.” These learners should be considered cherished assets. As educators, we need to nurture learners and demonstrate that it is possible to pass through the crucible of medical training without compromising one's humanity and integrity.
Dr. Elnicki would like to thank Lou Pangaro for his critical review and Sylvia Ford for her assistance with the manuscript.
The author's prior work in the area of student well-being has been supported by the Shadyside Hospital Foundation.
1 Taylor JS. Learning with emotion: A powerful and effective pedagogical technique. Acad Med. 2010;85:1110.
2 Knowles MS, Holton EF, Swanson RA. The Adult Learner. 5th ed. Woburn, Mass: Butterworth-Heinemann; 1998.
3 Skeff KM. Enhancing teaching effectiveness and vitality in the ambulatory setting. J Gen Intern Med. 1988;3(2 suppl):S26–S33.
4 Elnicki DM, Curry RH, Fagan M, et al. Medical students' perspectives on and responses to abuse during the internal medicine clerkship. Teach Learn Med. 2002;14:92–97.
5 Ogden PE, Wu EH, Elnicki MD, et al. Do attending physicians, nurses, residents and medical students agree on what constitutes medical student abuse? Acad Med. 2005;80(10 suppl):S80–S83.
6 Elnicki DM, Kolarik R, Bardella I. Third-year medical students' perceptions of effective teaching behaviors in a multidisciplinary ambulatory clerkship. Acad Med. 2003;78:815–819.