Before my first day teaching at a Kenyan children’s hospital, an American friend warned me of the intensity with which my fellow pediatricians would question the medical students. “It’s uncomfortable,” she said, lips quirking to one side. I assumed that I knew what she meant: that, at the bedside, the line between teaching and humiliation can be blurred. And moreover, that despite borders and cultures dividing global medicine, some experiences are universal.
The first patient I saw that day was a little boy, six years old, lying in a bed on the far side of the ward, beneath a large window. Sunlight streamed in, illuminating a massive, ulcerating jaw tumor—a classic example of endemic Burkitt lymphoma, curable but disfiguring. I thought of my own son, skipping off to his Kenyan school, and I reminded myself sternly, “I am supposed to be prepared for this.” Icy sweat trickled down the back of my neck. Yet I was not prepared for this. Observing my colleague as he examined the patient, I wondered when I had last relied solely on a physical examination to make critical treatment decisions, without recourse to laboratory studies or imaging. This was a different, humbling sort of discomfort.
Moving on, the next patient on the ward had hemophilia and a joint bleed. Such cases, I quickly learned, were uncommon, appearing only every few years. I asked the students what they already knew about hemophilia. Hands flew up into the air. The students shyly described the pathophysiology. One sketched the clotting cascade in a tiny reporter’s notebook and passed it around the group. “How would you manage this patient?” I asked. Some shuffled their feet. Others looked at the floor, a time-honored, if ineffective, method of disappearing under the teacher’s nose. When the silence persisted, my colleague called for answers from individual students by name. Each student was then permitted to “phone a friend” for assistance—slightly embarrassing, perhaps, but not shameful. When the collective fount of knowledge finally ran dry, students scribbled down the remaining questions for later study. The definition of a rare disease might be relative, but the enthusiasm of medical students for studying the exotic appeared to be universal.
Finally, the discussion moved to treatment options. Without factor isolates, the only treatment available to manage the complications of hemophilia in the hospital was whole blood or packed red blood cells. I did not want to dwell on inaccessible technologies, but the students were astute. They perceived the gaps in both their knowledge and their resources. They did not pretend it was fair, but neither did they dwell on the unfairness when there was so much to learn and do.
There was real discomfort present, lingering in the silences between questions and answers, settling in where expectations went unmet. It was sometimes awkward, yes, but it was not humiliating, not cruel, not abusive. No one was berated for ignorance or chastised for a wrong answer. And yet, as I listened and learned myself, I began to think that this sort of discomfort was a good and necessary thing. These young not-quite-doctors were allowed to feel, truly, the chasm between what they knew and what they needed to know to become great healers. They were given time and space in which to appreciate the awesome nature of what they were undertaking as students of medicine.
I feel this discomfort too, I have realized. Whenever I considered how much I had to learn in Kenya, of course, but also each time I see a child with a rare tumor or an unusual complication. Each time protocols fail, forcing us to move beyond the clean bounds of gold standards. Each time I tell a family that nothing is certain about their child’s future, that we left the textbooks behind at the first relapse and are now beyond even case reports. While I was in Kenya, one of my patients was diagnosed with a second malignancy. It was—in my fluent second language of medicine—therapy-related. We caused it, but we do not know how to cure it.
I thought about this discomfort often when I returned home to my students and medical school. Like many institutions, we are still searching for balance. We place a great deal of weight on student satisfaction, yet students still report experiences of humiliation and mistreatment. And I fear that something crucial is lost if we regard discomfort as an unequivocally negative experience, if we fail as teachers to separate humility from humiliation.
Discomfort is good, and it is necessary. It reminds us to be humble when so many cultural forces are telling doctors and future doctors just the opposite. I teach my students this: It is far better to acknowledge the limits of one’s knowledge and skill—and the limits of scientific medicine—than pretend those limits do not exist or, worse, proceed ignorant of those limits.
Acknowledgments: The author wishes to thank Dr. Trevor Jensen for his help editing initial drafts of this essay.