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Slow Medical Education

Wear, Delese PhD; Zarconi, Joseph MD; Kumagai, Arno MD; Cole-Kelly, Kathy MSW

doi: 10.1097/ACM.0000000000000581
Perspectives

Slow medical education borrows from other “slow” movements by offering a complementary orientation to medical education that emphasizes the value of slow and thoughtful reflection and interaction in medical education and clinical care. Such slow experiences, when systematically structured throughout the curriculum, offer ways for learners to engage in thoughtful reflection, dialogue, appreciation, and human understanding, with the hope that they will incorporate these practices throughout their lives as physicians. This Perspective offers several spaces in the medical curriculum where slowing down is possible: while reading and writing at various times in the curriculum and while providing clinical care, focusing particularly on conducting the physical exam and other dimensions of patient care. Time taken to slow down in these ways offers emerging physicians opportunities to more fully incorporate their experiences into a professional identity that embodies reflection, critical awareness, cultural humility, and empathy. The authors argue that these curricular spaces must be created in a very deliberate manner, even on busy ward services, throughout the education of physicians.

Dr. Wear is professor of family and community medicine, Northeast Ohio Medical University, Rootstown, Ohio.

Dr. Zarconi is system vice president for medical education and chief academic officer, Summa Health System, Akron, Ohio, and professor of medicine, Northeast Ohio Medical University, Rootstown, Ohio.

Dr. Kumagai is professor of internal medicine and medical education and director, Family Centered Experience and Longitudinal Case Studies Programs, University of Michigan Medical School, Ann Arbor, Michigan.

Ms. Cole-Kelly is professor of family medicine and director, Communication in Medicine and Foundations of Clinical Medicine Seminars, Case Western Reserve School of Medicine, Cleveland, Ohio.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Dr. Wear, Northeast Ohio Medical University, 4209 State Route 44, Rootstown, OH 44272; telephone: (330) 325-6125; e-mail: dwear@neomed.edu.

Slow down, and the landscape changes.1

It was bound to happen: McDonalds in the shadows of ancient landmarks. But it was also bound to be resisted: Carlo Petrini organizing the campaign to stop the fast food restaurant when it sought to locate near the Spanish Steps in Rome in 1986. This local, focused protest turned out to be the genesis of the Slow Food movement, formally launched in 1989 to “counteract fast food and fast life, the disappearance of local food traditions and people’s dwindling interest in the food they eat, where it comes from, how it tastes and how our food choices affect the rest of the world.”2 Since that time, others throughout the world have launched similar grassroots movements regarding diverse aspects of contemporary life, such as Slow Travel, which involves a “deeper type of travel by staying in one place longer and seeing the things that are close to you.”3 All share a commitment to challenge the beliefs that “fast is good and faster is better,”4 that nonstop hyperactivity is a natural state, and that multitasking is a desirable way of living in today’s world, beliefs that are present in almost all aspects of modern life. As Milan Kundera5 puts it, “Speed is the form of ecstasy the technical revolution has bestowed on man.”

Clinical medicine has similarly been affected by a “slow medicine” movement in which attempts are made to balance the attraction of technology, speed, and efficiency with listening, collaboration, and human presence.6–8 But what about medical education? Medical education has not escaped attempts at streamlining, attempts that valorize and reward speed, economy, efficiency, and outcomes. While homage is paid to connecting with patients, to the virtues of compassion and respect, to the ideal of honoring human differences in all their manifestations, medical education offers only brief asides for students’ deep consideration of these values. Furthermore, despite the commonly heard call to include different forms of reflection in clinical education and practice,9 one is often expected to learn to reflect “on the fly” and by osmosis, and only after the real work of medicine is done. This trend is also driven by necessity in the clinical years: The volume of work assigned to residents and the increasing constraints on the time they have to accomplish that work put a premium on efficiency, possibly at the cost of teaching and learning.10 The current focus on competencies may exacerbate this trend, since there has been a shift from time spent in education and training to outcomes achieved.11,12 Indeed, the traditional time-based approaches have been somewhat disparagingly labeled the “tea bag model of medical education,” which supposedly envisions learners, like tea bags, as needing to be “steeped” in specific areas for a certain period of time as part of the educational process.13

Compared with the sum of all educational experiences in the undergraduate medical curriculum, there are very few formal opportunities for students to puzzle over the personal challenges in becoming physicians, among them the disparate and contradictory values enacted throughout the curriculum.14–16 The medical education train traditionally relies on a speed that varies little, beginning its journey through the voluminous basic sciences followed by a grand tour through the clinical specialties with brief stops for assessment based on efficient rubrics. Often, reflective exploration is discouraged because there is too little time to get from point A to point B; one must jump off the train to even take in the view.

Is this the best way to educate doctors? This rush to efficiency, benchmarks, and fulfillment of competencies comes at a cost: the loss of the quiet moments of thoughtful reflection and dialogue, of appreciation and understanding. It would be shortsighted not to recognize that learners can achieve milestones and develop competencies through a slower and deeper process, yet too few of these examples are described in the literature.

Are there ways to slow medical education down—not in a literal sense, but in a more balanced way, without requiring additional time in the curriculum—to identify times when speed is warranted and when slowness is desirable, “what musicians call the temp giusto—the right speed?”17 When does it make sense to slow down the education of physicians?

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Going Slow: Some Possibilities

Slow reading in the medical curriculum

No one who spends any time in higher education settings fails to notice how much time we all spend with our faces glued to computer screens. Students’ relationships to screens are even more extensive: At any given time, their laptops, always open, direct their attention to a lecturer’s slides, to hyperlinked sites related to the subject at hand, to social networking sites, to a game of solitaire, to an e-mail from home. Sometimes, and often simultaneously, the vibrating buzz of their smartphones alerts them to short bursts of words in text messages, tweets, or on Facebook. At home, it’s more of the same: a focus on the computer screen as they review the day’s slides and follow readings offered as links in their paperless syllabi, often with the television on and always with their phones nearby. Indeed, the world of reading seems to involve fragmented hyperlinking rather than full engagement with whatever content is at hand.

In addition to the kinds of reading described above, we read all day long in other ways, in large part unconsciously: the newspaper, billboards, menus, signs, receipts, and lists, all of which are relatively “shallow” and occur quickly.18 Thus, “we have become very good at collecting a wide range of factual tidbits, [but] we are also gradually forgetting how to sit back, contemplate, and relate all these facts to each other.”19 Thinking, it seems, “has taken on a ‘staccato’ quality.”20

Moreover, with the Internet as an all-purpose medium, we begin to look to it as the source for all the information, knowledge, and entertainment we need. Mark Bauerlein21 writes eloquently of this phenomenon:

Screen readers often race across the surface, dicing language and ideas into bullets and graphics, seeking what they already want and shunning the rest. They convert history, philosophy, literature, civics, and fine art into information, material to retrieve and pass along. That’s the drift of screen reading. Yes, it’s a kind of literacy, but it breaks down in the face of a dense argument, a Modernist poem, a long political tract, and other texts that require steady focus and linear attention—in a word, slow reading. Fast scanning doesn’t foster flexible minds that can adapt to all kinds of texts, and it doesn’t translate into academic reading.

In a “virtual” longitudinal study of the published literature on Web site use and on the information-seeking behavior and preferences of young people, the authors found that online readers read differently.22 They describe the emergence of “new forms of ‘reading’ as users ‘power browse’ horizontally through titles, contents pages and abstracts going for quick wins.” They also describe the findings of Internet research showing “that the speed of young people’s web searching means that little time is spent in evaluating information, either for relevance, accuracy or authority.” The relevance of these differences in reading to the education of physicians is illustrated eloquently by Christine Rosen,23 who wrote that reading a Dostoevsky novel requires:

That you must first submit yourself to the process of reading it—which means accepting, at some level, the author’s authority to tell you the story. You enter the author’s world on his terms, and in so doing get away from yourself. Yes, you are powerless to change the narrative or the characters, but you become more open to the experiences of others and, importantly, open to the notion that you are not always in control. In the process, you might even become more attuned to the complexities of family life, the vicissitudes of social institutions, and the lasting truths of human nature. The screen, by contrast, tends in the opposite direction. Instead of a reader, you become a user; instead of submitting to an author, you become the master. The screen promotes invulnerability. Whatever setbacks occur (as in a video game) are temporary, fixable, and ultimately overcome. We expect to master the game and move on to the next challenge. This is a lesson in trial and error, and often an entertaining one at that, but it is not a lesson in richer human understanding.

Opportunities for slow reading in the medical curriculum are one way educators can offer and urge students to form a more meaningful, multifaceted relationship with ideas and stories, not by “reading as slowly as possible at all times, but rather exercising the right to slow down at will.”24 Physical rather than digital texts are a better medium for slow reading, the latter being far better suited for scanning and searching for small bits of information, for hopping from one page to the next via hypertext; the difference between these actions and reading, say, a printed story, essay, or book is the difference between gobbling and savoring.1 Moreover, slow reading is not just for the acquisition of some kinds of information or knowledge. It has, according to John Miedema,25 both the “serious purpose of reading non-fiction to better understand things, and the playful imagination of reading fiction to see things in new ways.… The act of slow reading exercises our imagination to develop interiority, our psychological framework.”

Where might we encourage slow reading in the medical curriculum? Assigning readings and merely hoping that students read them in this manner is pure folly in a curriculum driven by the intense acquisition of information and skills, assessment, and other modes of performance that sort students into the various specialties. Perhaps the most apt places for slow reading in the medical curriculum are where we craft experiences for students to more fully comprehend their patients’ distress and bewilderment at being ill, their suffering, their moments of transcendence, their healing, or to more fully comprehend the impact of these experiences on students’ professional identity development. In particular, literature and literary methods can teach medical students how to listen more fully to patients’ stories. The theoretical luminaries of the field of literature and medicine—Joanne Trautmann Banks, Suzanne Poirier, Kathryn Montgomery, and Rita Charon, among others—argue that one of the richest sources of knowledge about the human experience of illness is literature. Rita Charon26 explains that:

Illuminating patients’ experiences in the full, rich, nuanced particularity seldom if ever available elsewhere, literary accounts of illness widen physician–readers’ knowledge of the concrete realities of being sick and enable these readers to appreciate their own patients’ stories of sickness. By mobilizing the imagination, literary works engage the reader more fully than do clinical, sociologic, or historical descriptions, even when the same experiences are portrayed.… By reading narratives of illness written by gifted writers, physicians can more precisely fathom the fears and losses of patients with serious illnesses, identifying in fictional characters and then in their own patients the inevitable conflicts and uncertainties that sickness brings.

“Nuanced particularity,” “mobilizing the imagination,” “engag[ing] the reader”: This is not the stuff of fast reading. Such reading is meditative, allowing us to “indulge our subjective associative impulse,”27 to bend over together in such thoughtful contemplation of a subject that “our heads touch.”26 Such reading in medical education settings is a means to deepen and enlarge the quality of students’ attention to patients and to richer perceptions of patients’ realities, as well as to the mystery inherent in matters of living and dying.

In a related activity, one is required to “slow things down” when one writes. Writing in this way is not meant to serve an instrumental purpose (e.g., writing notes from lectures, writing a clinic note); it is meant to be reflective, to engage oneself and one’s personal insights, values, and beliefs in acts of interactive and moral imagination.28 Writing in this manner fully engages one’s self in acts of exploration and discovery; forcing someone to commit ideas, thoughts, feelings, and memories to paper prompts a remembrance of past events, a “self-retelling” of their significance, and a broadening of perspectives through seeing things in new and different ways. Writing interrupts the automaticity of thought and taken-for-granted beliefs and reopens critical inquiry of personal assumptions, social interactions, and societal conditions.

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Slowing down in clinical settings

Having considered slow reading and writing, one must ask whether slowing down is possible in the clinical realm as well. In many clinical settings, slowness is an anathema. This is part necessity (think: trauma centers), part economic (think: bottom lines), and part cultural (think: faster is better). Moreover, an entire generation of physicians, and certainly everyone in the training pipeline, lives with increasingly “clipped, hit-friendly [metric-driven] brevity.… Young people hear, through the apotheosis of tweets, blog posts, Facebook updates, and sound bites as the core of communication, that short is always smarter and better than long.”29 So, in the electronic cacophony and informational deluge that threatens to overwhelm clinical medicine, where is the time for reflection?

According to Abraham Verghese,30 the physician–patient relationship has not escaped this orientation toward speed and efficiency. He describes two present-day approaches to patients: the “traditional” way and the “expedient way.” Using the former, the body is “a text that … must be frequently inspected, palpated, percussed, and auscultated.” The findings of this low-tech approach are added to other information such as, for example, the scent in the patient’s room, a family member’s perspective, or the timbre of the patient’s voice, all potentially critical contributions leading to a richer and more accurate understanding of what is going on with that patient. “And on this foundation,” Verghese30 continues, “data from the chart can be selectively applied.” Or as Salvatore Mangione31 puts it, “I’ve seen many cases in which technology unguided by bedside skills took physicians down a path where tests begot tests and where, at the end, there was usually a surgeon, and often a lawyer.” This, he maintains, is a result of “hyposkillia”—an overreliance on tests, the allure of the machine, and the demise of bedside teaching.

The expedient approach to clinical care is not taught directly but is learned by almost every medical trainee in the United States. In this approach, the patient is more an “icon” than a live person, with the chart as its surrogate, having been fully imaged, tested, and diagnosed in the emergency department—all at great cost—so that attendings, residents, and medical students meet a “fully formed iPatient” before actually seeing the “real” one in her bed after admission. Verghese30 identifies several problems that emerge, however, when the real patient recedes to a place where her body is merely offered up for a perfunctory bedside exam that takes time away from the computer screen containing her labs, images, medications, prior history, and other data.

Verghese30 argues that without taking time for the skilled and recurrent examination of the patient, “simple diagnoses and new developments are overlooked, while tests, consultations, and procedures that might not be needed are ordered.… In a health care system in which our menu has no prices, we can order filet mignon at every meal.” Much of this filet mignon is offered at certain academic medical centers where the most advanced tests and cutting-edge treatments are routinely offered, largely because of a cultural bias that everything must be done for everyone in the fast-paced hospital environment that discourages significant and sometimes time-consuming (i.e., relatively slow) conversations between health care providers, patients, and families. In these clinical settings, slow medicine might be considered as an alternative.

Victoria Sweet writes eloquently, in her memoir God's Hotel32 and elsewhere,33 of her 20 years at Laguna Honda Hospital in San Francisco, a place where slow medicine could thrive:

What I discovered was that the two ways of looking at the body—the modern and the premodern—the Fast and the Slow, as a machine to be repaired and as a plant to be tended—are both effective when they are applied to the right patient at the right time. For illnesses that come on suddenly—an inflamed appendix, a rip-roaring infection, a car accident, a heart attack—it is best to think like a mechanic—boldly, reductively. What is broken? What should I do to fix it? Desperate illnesses require desperate remedies. But not-desperate illnesses do better with not-desperate remedies. Diseases that come on slowly—chronic infections, complex medical conditions, the aftermath of the appendectomy, the heart attack, the chemotherapy—are best approached like a gardener, asking myself … not what is broken but what is working? What are my patient’s strengths and how can I support them? What can I do to nurture viriditas, the natural power of healing?33

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Other Considerations

Although computer applications have become invaluable assets in patient care, Verghese30 suggests that when one focuses almost solely on the data found on a computer screen, one misses out on “the joy, excitement, intellectual pleasure, pride, disappointment and lessons in humility … experience[d] by learning from the real patient’s body examined at the bedside.” Furthermore, one misses not only the lessons that the patient and his body can teach but also the lessons that the experience of doctoring can teach. Although we often like to think of the passage through medical school and residency as an education (or from an increasingly popular vocational perspective, as training), it is much more. These years represent some of the most intellectually, physically, and emotionally demanding of one’s life, and as such they represent one of the periods of greatest personal and professional identity formation and development. Much of the learning that occurs during this period is not formal; instead, the bulk occurs through interactions with patients, peers, and supervisors, during trying times, bearing witness to the very beginning and the very end of life and to traumatic events and to the periods in between. Lessons and insights derived from this period “go deep” within the self: They become part of tacit knowledge and, in the words of Michael Polanyi,34 “come to dwell within” us. It is this “indwelling” that confers such power to the “hidden curriculum”14 and provides the basis for personally held, lifelong memories and views on oneself, doctoring, patients, and medicine.

From this context arise what the novelist Virginia Woolf35 calls “moments of being.” According to Woolf, individuals spend the majority of their lives living in the “cotton wool” of unexamined daily existence, and only once in a great while, they encounter “moments of being” in which a specific moment in life assumes a primacy, a fundamental importance and significance for them. These moments of being arise from “this cotton wool, this non-being” like a violent shock, etching themselves permanently into memory.35 This phenomenon is particularly operant in the lives of medical students, especially during the clinical years. There are moments of being—moments of clarity and insight that are encountered in the presence of suffering and healing, death, and dying—that seem to focus one’s perspective in a permanent way. Some experiences may be positive, such as witnessing the look of confidence and power in a patient realizing her strength in illness, and others negative, such as the inability to relieve a patient’s pain or prevent death, but all enter into memory and affect one’s view of self, others, and the world. What is necessary to raise these moments of being to consciousness and to incorporate them in the development of a truly reflexive, humanistic approach to medicine is time. It takes time to gather these moments and to uncover them through reflection and dialogue with one’s mentors, companions, and colleagues. It takes time to learn from these moments and uncover their significance to, and connection with, deeply held views, values, and experiences. Finally, it takes time to incorporate these moments into a professional identity that embodies reflection, critical awareness, and compassion. To fully understand these moments in the context of doctoring, time must be set aside from daily pressures and activities.

Closely connected with these moments of being is a distinct way of thinking. In one of his later works, the philosopher Martin Heidegger36 made the distinction between calculative thinking and meditative thinking, the latter of which, according to Heidegger, is on the wane. Calculative thinking is analytical and “never stops, never collects itself.” It is tied to technology and its advance without critically inquiring of its meaning. Meditative thinking, on the other hand, “contemplates the meaning which reigns in everything that is.” It is a thinking that allows technology and things into our lives but refrains from giving them control. Heidegger also claims that meditative thinking allows us to keep ourselves “open to the mystery” of being and becoming. This is not to say that calculative thinking is itself bad—in medicine, it is essential; however, contemplative thinking is the means by which one can access the more human, experiential (and existential) aspects of medicine and allow its lessons to “dwell within us.”

Implicit in the use of reading and writing to prompt reflection is the closely associated activity of dialogue. Although reading and writing appear to be solitary acts, their use to enhance a reflective understanding of one’s emerging professional self must be tightly linked with a social act—that of dialogue. Because the self is defined only in its relationship to the other, identity formation—both personal and professional—is mediated through social interactions. Dialogues between learners and mentors and small-group discussions between learners and their peers serve as a space for the thoughtful exploration of thoughts, questions, and feelings of discomfort, ambivalence, and wonder. These spaces must be created in a very intentional manner: Even on busy ward services, brief periods of time may be taken to engage in thoughtful reflection and exploration through dialogue about critical incidents, patient encounters, ethical challenges, and in appreciation of moments of being—the human side of doctors and doctoring.

What does it mean to need time for “slowing things down” in an otherwise busy curriculum? Clearly, fast interventions and high-acuity experiences will always have their place in good clinical care and medical education. But if, as the current medical education establishment proclaims, reflection, professional identity development, and patient-centeredness are to be valued in the training of physicians, then the time and conditions needed to foster these characteristics have an essential place in curriculum design. By arguing for more time for these activities, we do not mean to imply that we are asking for more time to steep medical students, like tea bags, in the culture of medicine.13 On the contrary, time alone is necessary but insufficient for these changes: Moments of reflection and dialogue about significant events must be intentionally dedicated. Essentially, what we are proposing is intentional pauses in activity amidst the cacophony of monitors and machinery, the incessant call of pages, e-mail, texts, and Twitter, the distraction of overwhelming data and information, and conflicting personal and professional priorities. While Donald Schön37 posits that reflection-in-action is a seamless, oft-unconscious part of expertise, the ability to reflect-while-practicing needs time and space to develop. The point is that dedicated, intentional pauses in daily activities must be created and, at least during the years of education, separated from clinical care to facilitate the development of the fully reflective mindfulness of clinical practice. Learners also need time to watch their clinical teachers take time as well. As Abigail Zuger38 reminds us, “When you rush it, you get exactly the problems that now confound us all: consumer misery and medical mistakes galore.”

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