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Invited Commentaries

Illuminating Shadows: The Power of Learning by Observing

Ende, Jack MD

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doi: 10.1097/ACM.0000000000003017
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To the list of medical misnomers that now include pretibial myxedema (it’s found in hyper-, not hypothyroidism), pyogenic granuloma (it is neither pyogenic nor a granuloma), and superficial femoral vein (although it is femoral, it is actually a deep vein), I wish to add one that pertains not to clinical medicine but to medical education—“shadowing.” As the term typically is used, shadowing refers to a student following an instructor. The instructor goes on rounds, the student goes along; the instructor goes into an exam room to see a patient, the student follows. Shadowing differs from apprenticeship in that the duration of the former may be as brief as a few hours, and it differs from preceptorship in that the latter typically is more formal and occurs in the context of a course that may be a required part of a formal curriculum.

So, why is shadowing a misnomer? Because the term implies less light, rather than more. Yet, when shadowing works well, it can illuminate, stimulate, and move students to emulate what otherwise they might never observe. A recent example comes to mind.

A 57-year-old patient followed for mitral regurgitation and hypertension called my office to report shortness of breath for the past few days. An urgent appointment was arranged. I had an intern assigned to me that day. I could, of course, have had the intern see the patient on his own and then present the case to me. Instead, I opted for shadowing.

I briefed the intern on the patient’s past medical history and set the agenda for the evaluation. “Let’s go see him,” I said, “and determine whether his shortness of breath is due to heart failure, or something else. He tends to be anxious at times.” With the intern watching, I took the history, which revealed that the patient’s shortness of breath was episodic and more likely to occur during rest than with exertion. There was no history of chest pain, paroxysmal nocturnal dyspnea, or orthopnea. There was, however, a history of stress and worry over business matters. The vital signs revealed hypertension, 160/90 mmHg, but the oxygen saturation and pulse were normal. On physical examination, the lungs were clear. With the intern at my side, I pointed out that the jugular venous pulse was around 6 cm, abdominojugular reflux was not present, and the Valsalva response,1 which I demonstrated and had the intern repeat, was negative. I also had the intern listen to the patient’s heart so he could hear the mitral regurgitation murmur, while calling attention to how the murmur was “blowing” in quality, and continued into and through the second sound. Finally, I reviewed with the patient that his echocardiogram from 3 months before had not shown any changes in ventricular function from years past. The shortness of breath, I explained to the patient, did not appear to reflect congestive heart failure, angina, or worsening mitral valve disease. “More likely, it’s stress related,” I said. “Let’s see how you are doing in a week. However,” I explained, “I’d like to change your hydrochlorothiazide to chlorthalidone and recheck your blood pressure at that time. But let me know if the shortness of breath worsens.”

Outside the room, I called attention to what the intern and I were able to accomplish with the physical examination. I commented how that was one less echocardiogram, one less chest X-ray, and importantly, one less patient sent to the emergency department. I also highlighted the importance of the 1-week follow-up. My conversation with the intern, however, might have gone in other directions. I could have asked him, “What do you think?” I could have asked the intern to summarize the case and/or the decision-making process. And I could have gone into greater detail regarding the value of the physical exam. Debriefing, such as this, can be a powerful component in shadowing. In this case, however, I kept the debriefing rather brief. I chose to let the intern form his own impressions. Some would argue that a “teachable moment” was missed. But I felt in this case that the encounter might be even more impactful if it was left to stand on its own, like the policeman who deflects a “thank you” by saying, “Hey, I’m just doing my job.” After all, the essence of shadowing is one person watching another do his or her job.

In the taxonomy of approaches to learning, where experiential learning lies at the left end of the spectrum and passive attendance at the right, shadowing definitely falls toward the right. Learners may say (and do) very little as they shadow accomplished clinicians. I can vividly recall a few of my own experiences from medical school when I quietly observed skilled faculty—one, an endocrinologist; another, a rheumatologist—in their office practices. That was over 40 years ago! I remember thinking a lot about what I had observed those afternoons. Perhaps that was where I decided to pursue a career in internal medicine. Shadowing is increasingly made available (or should be) for prospective medical students. To rectify this misnomer and remove the negative connotation, should shadowing be renamed as “observation and reflection” or “aspirational education?”

No, I suggest sticking with “shadowing” and not apologizing for the term’s implied passivity. It is a powerful instructional modality. Shadowing should not be the only method employed when working with a learner in the office or hospital; in fact, it should be used sparingly, as opportunities to exercise one’s clinical skills remain the mainstay of clinical learning. But it definitely should be used. What shadowing provides, the chance to see how experienced clinicians approach their work, is not available with other forms of learning. In our zeal to provide active, experiential, learner-centered learning, with a focus on learners’ autonomy and independence, it is easy to forget how much can be learned just by observing, even from within a shadow.


1. McGee SR. Evidence-Based Physical Diagnosis. 2001.1st ed. Philadelphia, PA: W.B. Saunders Co.
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