Share this article on:

Tying Square Knots

Brown, Benjamin P. MD

doi: 10.1097/ACM.0b013e31828a6b9f
Teaching and Learning Moments

Dr. Brown is a first-year resident, Department of Obstetrics and Gynecology, University of Chicago Medical Center, Chicago, Illinois; e-mail:

Author’s Note: The author would like to thank Julie Taylor, MD, for her leadership of the Clinical Skills Clerkship and for her guidance during the writing of this essay.

It was my fourth year of medical school, and I was one of the instructors in a new clinical skills course, designed to prepare the rising third-years for their clerkships. I had just spent three weeks teaching a small group of nine students how to write a history and physical exam note, how to calculate fluid requirements, how to draw blood, and how to close an incision.

For the final exam, I was assigned to grade the suturing station. The first group of students came into the room, sat down, and confronted the waiting pigs’ feet, each with a neat laceration down the middle. As they sewed, I observed them one-by-one. They worked efficiently, and I went down the line, steadily checking off the boxes on my grading sheets. About halfway through the group, however, I paused. One student was tying the knot incorrectly, leaving the suture tangled on one side of the incision. My heart sank—without a square knot, she was not going to pass my station. My hand shook a bit as I showed her the grading sheet at the end of the exam, bearing the notice, “Come back this afternoon for extra practice with suturing.” She read the sheet with a disappointed shrug and went on to the next station. I handed in my checklists and got ready for the next group of students, but I couldn’t shake the sense of guilt. For the first time, I was responsible for a student’s failing grade.

I spent the rest of the day wondering how the students in my own small group had done on the exam. Would they remember the system I taught them for reading a chest X-ray? Would their notes have thorough treatment plans? Would they tie square knots? As I pondered the answers to these questions, I realized this stress felt oddly familiar—I often feel the same way when seeing patients.

As clinicians, we feel the growth or stagnation, success or failure of others as if it is on our shoulders, and the same is true as educators. Indeed, teaching and doctoring are rooted in very similar practices—we assess students’ strengths and weaknesses much as we assess patients’ symptoms. We tutor students using PowerPoints much as we counsel patients using handouts. We gauge students’ growth with exams much as we trend patients’ hemoglobin A1c levels. And, just as it is easy to blame ourselves when a patient’s diabetes remains stubbornly uncontrolled, it is easy to feel guilty when a student performs poorly on an exam.

Later that day, I met with the student who failed the suturing station. We practiced tying knots, and, in a matter of minutes, she was throwing perfect, square instrument ties. I congratulated her on finishing the course and wished her good luck on the wards. As she left, my guilt began to ease—this meeting had been good for both of us. We had each gotten the chance to practice difficult skills—suturing for her, teaching for me.

Throughout my academic career, I will have patients who don’t get better, and students who don’t pass an exam, in spite of their best efforts and mine. I expect those cases to be challenging, but I will do my best to see such experiences not as failures but as opportunities to reevaluate and to grow. I will do my best to see my relationship with each patient as a chance to become a better teacher and my relationship with each student as a chance to become a better healer.

© 2013 Association of American Medical Colleges