Training Medical Students How To Teach Helps Them Embrace Ambiguity

Just months away from our medical school graduation, we found ourselves teaching in the first-year physiology course we had taken what seemed like eons ago.

“Should you give fluids to a patient with a myocardial infarction?” a student asked.

We had spent the past four years learning from textbooks and doctors and patients. This teaching experience was making us realize how much we had learned and, more important, how much we had yet to learn.

“It depends,” we began, taking turns explaining how the location of the infarction (more commonly known as a heart attack) and the patient’s signs and symptoms determine whether to give intravenous fluids.

“How do you know what pressor to use?” another student asked, referring to the class of medications used to raise blood pressure.

“That’s a good question.” We looked at each other, wondering if either of us had an answer, and then uttered the sentence that became commonplace during our stint as student teachers: “We don’t know.”

In volunteering to help teach the course, neither of us anticipated that questions asked by first-year medical students would heighten our curiosity and passion for medicine. But they did. We looked for answers and followed up with the students who asked them. In the process, we also reflected on how to be better self-directed learners and more effective teachers.

When it comes to teaching, medicine is unique. In music and sports, for example, teachers and coaches tend to be experts, like a concert pianist or former professional soccer player. In medicine, it’s junior doctors who do a fair amount of the teaching. In one study about the transmission of medical knowledge, medical students estimated that one-third of their clinical education on hospital wards came from resident physicians — doctors in training only a few years out of medical school.

Even though teaching is a core skill for physicians, little emphasis has been placed on training residents how to teach. The Accreditation Council of Graduate Medical Education, the organization responsible for accrediting most of the graduate medical training programs for physicians in the US, has mandated that residency programs spend time training their residents how to teach. Many residencies even have dedicated resident-as-teacher programs. In reality, though, it is a challenge to prioritize such programs while residents are working 80 hours a week learning to care for patients.

That, in part, has been an impetus for the rise of student-as-teacher programs. As the name implies, these are designed to help medical students learn teaching skills. If they can begin their post-med school residencies with effective teaching strategies, they will be better prepared to transmit knowledge and teach the medical students they encounter and, in turn, be able to focus more of their time developing patient care skills.

Our experience teaching first-year medical students brought home another important benefit of student-as-teacher programs: They help students learn how to grapple with uncertainty and ambiguity.

In medical education, there is traditionally little or no focus on helping trainees build comfort within the “gray space” of practicing medicine. As one of our favorite teachers, Dr. Richard Schwartzstein, likes to say about patients who do not have classical symptoms of an illness, “Patients don’t always read the textbook.” Yet textbooks are the primary learning resource that we use as medical students, which may constrain our ability to acknowledge the full spectrum and variation of disease. Moreover, senior physicians often “pimp” students with obscure black-and-white factual questions. Many rightly argue that this old-school practice needs to change because uncertainty and ambiguity are intrinsic to the practice of medicine — and our ways of teaching and learning should reflect that.

In our experience as student teachers, we found ourselves embracing ambiguity instead of shying away from it. Explaining nuanced clinical topics to junior learners made us more aware of the limitations of our knowledge and our initial knee-jerk desire to provide black-and-white answers, like those found on board exams. Being able to reflect on our understanding of the topics we have taught has also given us more confidence to acknowledge context and complexity in medical care, which are often not captured fully in exams or textbooks.

Perhaps most importantly, we are learning to value academic humility, which is arguably a prerequisite for a career path that requires lifelong learning and curiosity. This made us more comfortable answering learners’ questions with, “I don’t know,” followed by, “Let’s look this up together” — a strategy we also plan to use in our interactions with patients.

Although more outcomes-based research needs to be done about peer teaching, existing research and anecdotes support many of our positive experiences as student teachers. A recent meta-analysis concluded that learners do just as well whether they are taught by student teachers or faculty members, alleviating a common concern often voiced by faculty members and student learners about “non-expert” student teachers.

In addition to having us teach medical students, the elective we took part in included how-to-teach sessions given by local clinician-educators. Such carefully designed student-as-teacher programs can benefit everyone involved.

The culture of medicine in which we learn and practice needs to evolve from “see one, do one, teach one” to more thoughtful ways of teaching and learning that embrace multi-dimensional thinking instead of black-and-white answers. Teaching medical students how to teach may be one way to build for them more nuanced, collaborative, and curiosity-driven learning environments. Ultimately, it is patients who will benefit the most from having doctors who are comfortable working with their patients in the increasingly nuanced world of medicine where uncertainty and ambiguity are common.

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