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A Pause for Reflection

Sklar, David P. MD

doi: 10.1097/ACM.0000000000000151
From the Editor

Editor’s Note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members.

I initially had planned to write this month’s editorial about the research and workshops presented at an international medical education conference that I attended in Prague, Czech Republic, a few months ago. I had taken careful notes of discussions about the development of the concept of best-evidence reviews of medical education research1 and how that could guide changes in our educational programs. I had also learned that workforce shortages not only are affecting the United States but also are a problem in many European countries. Government policies as well as economic forces appear to be exacerbating the shortages.2

These and other interesting topics of educational research were my intended subject for this editorial. But that changed on my last day in Prague.

On that day, my wife and I visited a town called Terezin, about an hour from Prague. Terezin had been an old fortress town that the Nazis converted into a concentration camp in 1940 and named Theresienstadt. There is now a museum at the camp that showcases the daily life and surviving photographs, movies, and artistic expressions of the people who lived there. This camp was different from the more well-known ones such as Auschwitz, where gas chambers were built for mass executions. Terezin was a way station and model relocation site where children went to school, artists painted and musicians performed, and a self-governing community developed. There were Jewish teachers for the children. There were Jewish physicians to care for the ill in an infirmary. Everything seemed to work so successfully that the camp was used for propaganda films to demonstrate to the world that the Jews were being well treated and the Jewish culture was flourishing in these specially constructed “camps.” The museum displays surviving artwork and a brief story of each artist, often a child. In most cases the story ended with transport and death at Auschwitz or another death camp.

On our tour we met a rare survivor of the camp, a man in his 80s, and it occurred to me that this horrific place was not a vestige of some long-gone dark ages but belonged to our own recent history. People who had lived in the camp still exist. I think the absence of gas chambers and the relative normality of the dormitory rooms, school rooms, and infirmary created an even more chilling impression than gas chambers would have, because in the recordings of daily life there were stories that made sense and that I could understand. Teachers taught students how to read and write. Doctors cared for the sick in the infirmary, saving many from typhus.

I could even imagine being one of those doctors, trying to stay focused on my work as the world around me collapsed. I wondered how I would have reacted, particularly when I found out what my patients’ and my own ultimate fate would be. Would I have stopped caring and given up? How would I have dealt with the knowledge that in a month or two, the people I had cured of terrible infections would be shipped off to be killed, and that I would soon follow them? I like to think that I would have carried on as best I could to reduce the suffering around me even if I could not affect the ultimate outcome. That is what most of the doctors who were sent to Terezin did. And I think they did so because deep within them there resided a strong belief about the importance of ministering to the needs of the sick and of doing what they could to reduce the suffering that was all around them. I thought about how their education had formed their identities as physicians,3 identities that gave them the foundation of beliefs and values to behave as they did even though none of them had been trained for the situation in which they found themselves.

The visit to Terezin made me realize that medical education must always have as its foundation the creation and nurturing of the identity of the healer. We can help our students to think through problems and reduce diagnostic error, we can coach them to improve their procedural competence, we can even teach them better communications and business skills. But all that and more must be built upon a base of humanism, compassion, and love for others. Even in that concentration camp, the doctors, inspired by these values, were able to use their skills to help those around them.

It is unlikely that any of our graduates will find themselves in the midst of a situation where masses of innocent people are being systematically slaughtered, although recent history shows that genocide continues around the globe. Even so, the physicians of Terezin have a message for them. The fact that those physicians continued to care and to heal despite immense pressures to do otherwise can serve as a reminder that caring and healing are the core of what physicians do.

David P. Sklar, MD

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1. Harden RM, Grant J, Buckley G, et al. BEME guide no. 1: Best evidence medical education. Med Teach. 1999;21:553–562
2. Pond B, McPake B. The health migration crisis: The role of four Organisation for Economic Cooperation and Development countries. Lancet. 2006;367:1448–1455
3. Jarvis-Selinger S, Pratt DD, Regehr G. Competency is not enough: Integrating identity formation into the medical education discourse. Acad Med. 2012;87:1185–1190
© 2014 by the Association of American Medical Colleges