As clinical faculty, we rarely get the opportunity to sit and observe without speaking. But on this day, that is what I was doing as I sat near the head of the bed and observed a medical student introduce herself. The student was starting her fourth year and had not performed well on her core clerkships. My task was to observe her carefully, identify problems, and suggest strategies for improvement.
The student was tentative and her voice wavered. Then she began to perform a physical examination and to ask questions that would be incorporated into a comprehensive history of present illness. The student sat at the foot of the bed, peering into the eyes of the patient intently. She did not smile as she talked to the patient. She appeared to be on a mission, holding a pad of paper and writing the patient’s answers to her questions conscientiously. She followed a standard script with little deviation regardless of the answers the patient provided. The student seemed anxious and lacked confidence.
The patient described her recent descent into illness. She was a 50-year-old woman who looked at least 10 years older. Over the past six months, she had lost 30 pounds and had been experiencing constant abdominal pain and vomiting. Her fingers sometimes turned blue, and she had to wear gloves even indoors. The doctors had done numerous tests but could not figure out what was wrong. Even though she knew this was a student interview, she wondered whether perhaps the student and I might have the answer. The student nodded gravely when the patient expressed her frustration with unremitting pain, illness, and uncertainty, and then the student said, “I am really sorry for all you have been through.”
I watched as the student examined the patient; I then repeated the examinations of the heart, lungs, and extremities with her to verify her findings. As we were completing our examination, a group of consultants arrived and waited for us to finish. We thanked the patient and told her we would try to return later after the consultants had gone. The patient smiled and thanked us for listening. “No one else has listened to me like this,” she said. “They come in, use words I don’t understand, and then they leave and another group comes in.”
The student presented the patient to me as we sat at a computer looking at the tests and results that were available for review. The student had a problem list: abdominal pain of unknown etiology, possible connective tissue disease, weight loss, anxiety. We talked about the differential diagnosis and some learning objectives. I shared some observations I had about her interviewing style, things she could do to develop more rapport with the patient, and how to follow up on some of the patient’s answers, rather than to rush on to complete all of her questions. I complimented her for her expression of compassion at the end of her conversation with the patient. As we were finishing, the consultants walked out of the room and rushed off to another consultation. The student looked at me awaiting guidance. Were we finished, or should we go back into the room? “Let’s go back in,” I said.
The woman smiled when we returned. “Oh, you came back,” she said. “Those doctors want more tests.”
We nodded. I thanked her for allowing us to do the history and physical. Unfortunately, we had no answers for her about the cause of her problems. The woman looked at the student: “Can you come and see me again?”
“Me?” asked the student.
“Yes,” said the patient.
“Well, yes, I will.” For the first time the student’s face relaxed and she smiled, first at the patient and then at me. Later, the student and I discussed how she had connected with the patient and how developing connections underlies much of the physician–patient relationship, allowing the transfer of important information and the development of rapport and trust.
Connections is also a theme that runs through much of medical education research: investigating how to make connections with patients, how to make connections with faculty and other clinical team members, how to make connections between basic and clinical sciences, how to create connections with communities and their needs. It sometimes seems that all the elements we need to make both medical education and the health care system work optimally are scattered like pebbles in the sand. Our job is to find them—often via research—and arrange them to make all the needed connections. Three of the Research in Medical Education (RIME) reports in this issue of the journal, discussed briefly below, remind us of the importance of connections in many of the areas of medical education research.
Brazeau et al1 investigated the mental health of matriculating medical students and found that it is better than that of their college-age peers. This is notable because studies demonstrate that during the clinical years, medical students have significant rates of burnout and depression. The authors suggest that the training process and learning environment may contribute to the worsening of medical students’ mental health over time. This connection is one more alert to medical schools to find ways to improve the training process and learning environment. It will certainly be difficult for students to learn effectively and to make the necessary connections to their patients, teachers, and communities if they are struggling mentally and emotionally.
Cristancho et al2 used a variety of research strategies, including having participants create drawings, to explore the thought processes of surgeons during challenging surgical situations. Among its findings, this innovative study demonstrates novel connections between how surgeons think about a problem and how they describe problems verbally and visually. This study suggests new methods for unlocking the secrets of expert thought processes through drawings and for communicating those processes to learners.
Finally, Boscardin et al3 describe factors associated with positive changes in medical students’ intent to practice in underserved areas. These include having field experience in community health, learning another language, learning about health disparities, and becoming more aware of the perspectives of individuals from different backgrounds. Also, students from schools with a recognized social–community commitment were more likely to reaffirm their intent to practice in underserved areas. These findings reveal connections between what we in academic medicine can do and how our actions can be helpful as we attempt to address physician maldistribution as well as overall future workforce deficits.
The above three articles focus on a few of the several topics presented in this issue’s RIME collection, which includes reports about competency, assessment, patient centeredness, the learning environment, student characteristics, thinking and problem solving, expertise, and the workforce. These topics are impressive, but how do they compare to areas previously identified by medical education researchers as important ones, or to those areas most frequently published about? Do this year’s RIME reports investigate the most important topics, and if not, why not?
In 2007, Todres et al4 found that in 2004 and 2005, the major topics of medical education published in selected leading journals were assessment and examinations, curriculum design, professional development, learner characteristics, technology in medical education, and teacher development. Chen et al5 have called for moving from research about learner-oriented outcomes to patient outcomes. On the other hand, Cook and West6 caution us that the goal of patient outcomes is not an adequate one for medical education research. They make compelling arguments about why we need to continue to consider student outcomes as well as patient outcomes in a balanced way as we evaluate the importance and impact of medical education research. Cooke7 has decried the limited scope of education research, which has not been tackling the most important problems affecting our health care system. Carline8 has documented the limited funding available to support medical education research, which may explain the inability of investigators to undertake a more ambitious research agenda. As you read the 2014 RIME reports, ask yourself whether they address the concerns noted above. I believe those reports provide valuable insights that are focused mainly on undergraduate medical education, and do so in spite of limited funding to support research.
It is of some note that the area of medical education that has received consistent federal funding—graduate medical education (GME)—has not generally translated that funding into a vigorous medical education research agenda. Perhaps partly as a result of limited evidence of educational effectiveness, GME has come under scrutiny by governmental agencies, which led us at Academic Medicine to focus our 2014 Question of the Year9 upon GME. In this issue of the journal we present selected responses from readers to that question, which was “How can we ensure that our graduate medical education system will prepare trainees for practice in new systems of care delivery?” The thoughtful responses identify critical issues that are, understandably, somewhat different from those identified by the RIME reports, including population health, interprofessional teams, culture change, cost consciousness, and faculty development. Taken together, the RIME reports and the Question of the Year responses represent attempts to develop new educational approaches and connections that will help solve the pressing problems facing our health care system.
Our lives in medicine often oscillate between the large questions addressed through research or policy development and the personal manifestations of such questions, exemplified by the story of the encounter of my student with her patient. Each informs the other, and the research and stories must resonate with each other to be authentic and true. As I reflect upon my student and her patient, I can’t help but think that what was most important for both the student and patient was the connection they made with each other amidst the chaos of an otherwise difficult and frustrating health care environment and my own well-intended efforts to provide feedback. We must continue to study the ways that we can improve that environment while nurturing the many important connections that develop between our patients, learners, and teachers. I hope the RIME reports and the responses to the Question of the Year help all of us to find answers to the many questions facing our health care system, and also help us to become the best educators and physicians that we can be.
David P. Sklar, MD
1. Brazeau CMLR, Shanafelt T, Durning SJ, et al. Distress among matriculating medical students relative to the general population. Acad Med. 2014;89:1520–1525
2. Cristancho SM, Bidinosti SJ, Lingard LA, Novick RJ, Ott MC, Forbes TL. What’s behind the scenes? Exploring the unspoken dimensions of complex and challenging surgical situations. Acad Med. 2014;89:1540–1547
3. Boscardin CK, Grbic D, Grumbach K, O’Sullivan P. Educational and individual factors associated with positive change in and reaffirmation of medical students' intention to practice in underserved areas. Acad Med. 2014;89:1490–1496
4. Todres M, Stephenson A, Jones R. Medical education research remains the poor relation. BMJ. 2007;335:333–335
5. Chen FM, Burstin H, Huntington J. The importance of clinical outcomes in medical education research. Med Educ. 2005;39:350–351
6. Cook DA, West CP. Perspective: Reconsidering the focus on “outcomes research” in medical education: A cautionary note. Acad Med. 2013;88:162–167
7. Cooke M. A more ambitious agenda for medical education research. J Grad Med Educ. 2013;5:201–202
8. Carline JD. Funding medical education research: Opportunities and issues. Acad Med. 2004;79:918–924
9. Sklar DP, Weinstein D, Carline JD, Durning SJ. 2014 question of the year. Acad Med. 2014;89:1