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Teaching and Learning Moments

The Burdened Learner: Clinical Wards and the Effects on Student Curiosity

Kong, Nathan W. MD; Hauser, Joshua MD

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doi: 10.1097/ACM.0000000000003140
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I was presenting my first patient of the day, a 68-year-old woman admitted with dyspnea. Dr. Smith was the new attending that week, and she already seemed annoyed, like she had somewhere else to be. I had just finished rattling through the morning labs and reading the chest X-ray. My heart was beating rapidly as I started my summary statement. I had been up with my wife the night before practicing what I was going to say at this point. I was even going to present a study which discussed the role of inflammatory markers in acute asthma exacerbations. I wanted to make a great first impression.

But before I could finish, Dr. Smith said, without looking up from her paper, “The patient is not on any anticoagulation. What medication would you start her on?” I stared at her blankly. I was so caught off guard that I barely remembered what she asked. “Warfarin?” I said, with no confidence at all. She looked at me, tsk-ed, turned to the resident, and said, “Start Lovenox.” I caught the intern’s eye, who looked empathically at me as if to say, “Don’t worry, we’ve all been there!”

I wanted to ask Dr. Smith why this patient needed anticoagulation. Why was warfarin not the correct answer? Why did she choose Lovenox? But most of all, I wondered if I was a bad student for not knowing the answer. I didn’t ask any of those questions. My turn to talk was over, Dr. Smith seemed like she was in a rush, and I was too embarrassed to draw any more attention to myself.

As a third-year student, I was troubled by how often my curiosity for learning was replaced by a fear of compromising my “clinical performance” or being judged. I spent much of my psychological energy thinking not only about when to ask questions but also specifically what questions to ask. Would I be seen as unprepared? Naïve? Even worse—lazy? To combat this, I stifled my curiosity.

In the classroom, if I had a question, I would ask it. “There are no dumb questions,” we were told. On the wards, I felt as if that standard no longer applied. I was fearful both that my questions would slow or inhibit patient care and that I would be considered ignorant for my curiosity. Before I opened my mouth, I ran a mental checklist: Was my question too easily answered? Should I already know the answer? Would I be judged for asking (or not asking)? There is an expectation on the wards that students know everything about their patients. While this goal is meant to encourage students to understand as much as possible about a patient, it can also lead to the expectation that they know the answer to every question about the patient and his or her condition, an unrealistic standard.

We expect medical students to have all the requisite knowledge they need from the beginning of the rotation. If they don’t, their evaluations might say that they are “an enthusiastic student but could spend more time reading and studying.” In the classroom, however, the assumption is that students do not have the knowledge that the class is trying to teach and that competence grows throughout the course. It would be ludicrous to give an exam on the first day of a course with the same weight as one given at the end. But on the wards, first impressions stick, especially in an era of fleeting relationships. Not being able to answer the attending’s first question may be as detrimental, if not more, to others’ perceptions of your competence as not being able to answer the attending’s last question.

Medical schools are increasingly implementing early clinical experiences as a way to smooth the transition to seeing patients on the wards. This puts us at risk of disregarding the “student” part of medical school. As they start to behave, think, and feel more like medical professionals, a potential unintended message is that students have all the knowledge that medical professionals should have. Students are quick to detect this, and when they fail to meet that expectation, they might hide their incompetence and suppress their curiosity.

The transition from medical student to resident looks different for everyone, and there are varying levels of progression. Hospitals, faculty, and medical schools can do a better job of supporting students through this necessary transition by better fostering an environment of active curiosity. We should get rid of the false dichotomy of praising students who can recite Virchow’s triad while rolling our eyes at those who ask who Virchow is. If we don’t, students will continue to stifle their curiosity. In the end, a system that allows for the uninhibited flow of wonder and curiosity will continually improve itself—for students, residents, faculty, and patients.

An Academic Medicine Podcast episode featuring this article is available wherever you get your podcasts.

Copyright © 2020 by the Association of American Medical Colleges