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Case-Based Suffering

Aronson, Louise MD, MFA

doi: 10.1097/ACM.0000000000001606
Teaching and Learning Moments
AM Rounds Blog Post

L. Aronson is professor of medicine, Division of Geriatrics, University of California, San Francisco, School of Medicine, San Francisco, California; e-mail: Louise.aronson@ucsf.edu; Twitter: @LouiseAronson.

An Academic Medicine Podcast episode featuring this article is available through iTunes.

Not long ago, I sat in on an innovative “case-based learning” session at a medical school I was visiting, an institution rapidly acquiring a reputation for educational courage and innovation. In a small workshop room equipped with a communal table, white board, and video monitor to which one student’s computer could be attached so all could see what she scribed on behalf of the group, second-year students asked smart questions about three clinical cases related to their major course that block. They refined insightful queries about what was going on with the relevant organ systems, how certain drugs worked, and which symptoms had clinical import.

But in two hours of case discussions, only one student murmured a comment in response to the pathos of the patient’s situation. After just the first year of what would be at minimum a seven-year process, these medical students had learned to ignore the evident suffering described in their hypothetical cases—a young boy’s fear as he gasped for breath during an asthma attack, a healthy middle-aged man’s sudden loss of limb and livelihood, and an older woman’s repeated vomiting as a result of food poisoning.

After the session, I commented on this total focus on the pathophysiology and pharmacology to the course director, who had been lauded by my hosts as their best and most creative teacher. He said the curriculum was designed to encourage focus. It wasn’t possible to teach pathophysiology and clinical care simultaneously, he said, adding that such an approach was too confusing and overwhelming for the students. They needed these fundamentals first. The patient stuff, he said, was addressed elsewhere in the curriculum. He relayed all of this with evident thoughtfulness, commitment to his learners and to medicine, and without irony.

Walking down the hallway to my next appointment, I thought about how quickly people absorb the messages we don’t even realize we’re sending, much like the teenager whose mother tells him to always stop at stop signs but rolls through them herself when in a hurry. It’s been well documented for years that we teach our learners how and when not to care for patients via a similar unspoken or hidden curriculum.

It is challenging to tackle basic science and clinical medicine simultaneously, though more and more schools are trying. But that isn’t even what I was talking about.

It’s easier in many ways to teach medical science without knowing much about the patient as a unique human being and without expectations of feelings for her or him. The patients in our case discussions work well as abstractions or generics, more or less interchangeable vessels for the pathophysiology new doctors must master. We can focus just on the lungs or the blood tests or the remarkable images that now pop instantly onto our screens. We can pretend that a liver is a liver is a liver, that all broken bones have a similar impact on the bodies and lives they inhabit, and that medicine is about diseases and organs rather than people and lives.

Alternatively, we can take just a few seconds to recognize the human facts of the situation, letting our learners know with facial expressions and brief words of compassion, horror, and concern that it’s natural—and, better yet, desirable—for doctors to feel sad when their patients are suffering. When we don’t, when students are expected to read about a small boy who can’t breathe and think only about the child’s lung function, we teach them that being a doctor means not responding to distress in normal ways, including, I fear, not caring.

Acknowledgments: This work was supported by a Gold Professorship from the Arnold P. Gold Foundation.

Louise Aronson, MD, MFA

© 2017 by the Association of American Medical Colleges