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The Teachable Moment

Bell, Sigall K. MD; Misono, Alexander

doi: 10.1097/ACM.0b013e3181d25fd3
Other Features: Teaching and Learning Moments

Dr. Bell is assistant professor of medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.

Mr. Misono is a fourth-year MD/MBA student, Harvard Medical School and Harvard Business School, Boston, Massachusetts.

“I'll send your prescription to that pharmacy. Under your plan, it should be two dollars,” my attending said. Again, our patient nodded. <click> <click> <click> We began entering the necessary information into the computer. The clicks slowed, however, when we noticed that our patient slowly pulled one crumpled dollar bill out of her wallet. She sighed, and paused.

As I read my student's reflection, I was struck by the lessons he had learned. He found himself resisting the urge to reach for his back pocket and pull out his own wallet, so as not to embarrass or insult the patient. He pondered the “slippery slope” of doing so and wondered whether the feelings he had for this woman were empathic in nature, despite their differences.

I was neither her gender nor did I share her upbringing nor had I ever lived in a neighborhood like hers. I spent only 10 minutes conversing with her about problems I've never experienced myself. How could I step into her shoes? However, there is something about being human that binds us together. I wanted to help simply because she needed it, and nothing more.

And after further reflection, he noted the crucial difference a single word can make.

Only after reviewing the interactions many times in my head did I notice that my attending did not say “it should be only two dollars,” but rather “it should be two dollars.”

Omitting the word “only” meant omitting judgment and preserving the patient's dignity. He took away all of these lessons from one brief patient interaction, even though not a single of them was explicitly taught.

My student's reflection reminded me that trainees really do watch their teachers' every move and learn from what they see “on the job,” even when those behaviors are not scripted. His reflection also underscored that it often takes designated time for reflection to reveal important lessons. Time and again, our students tell us that it isn't until further contemplation that they come to a key realization. And so I think that one of our biggest challenges as modern-day educators is to actively expand the definition of “teachable moments”—those poignant opportunities to provide crisp clinical lessons—to include moments of humanism as well. The opportunity to discuss charity, empathy, and mindful communication on the learning agenda is arguably as important as the accompanying lessons about hypertension, pharmacology, and insurance coverage. In the frenetic pace of medical practice and education, it seems to me that these humanistic moments are often otherwise lost.

I can't help but wonder about the $2 stories, like the one my student recorded in his reflection, that we miss, the ones that don't hit the radar, the ones after which we forget to pull up a chair and talk with our students, even for just a minute, about what happened. I remind myself that the very point of doing so would speak volumes. It would emphasize for students that this experience was important enough for the attending to mention. Recognizing our role in patients' stories can bring humanism to the bedside in a tangible way.

Sigall K. Bell, MD

Alexander Misono

© 2010 Association of American Medical Colleges