The three codes every resident must learn to break over the course of their education
Aut disce aut discede
Real conversation in America is almost gone. Social interaction has become so terse as to be essentially nonexistent. We have been hoodwinked into believing that we are so much better “connected” than any other generation has ever been. Hogwash! Never has a country had more but enjoyed it less. Who decided that it was important to let your closest 900 BFFs know that you’re having trouble having a bowel movement. Is there any reasonable expectation of privacy or self-reliance left in the 21st century?
This month we set our sights on education, which is on everyone’s instant fix list, and which no one seems to understand. Let me start by saying that education should not be a time of your life, but a continuum throughout your life, from birth to your dying breath.
For the sake of this discussion – which will eventually get to our residents – we will define education not so much as facts, but as the acquisition and utilization of tools to demystify symbolic codes that govern our entire existence. Education is for survival, for vocation, for social adaptation, for self-expression, for personal development and spiritual completeness. We have been overly influenced by social Darwinists, who in the late 19th century decided education was to, “fit children to life” in an industrial society. There was no intention of guiding them toward eternal questions and investigation of meaning. This was followed by Rousseau’s romantic progressives who believe only in drawing out a person’s innate nature and not the imparting of information or the wisdom which accompanies it.
I am clearly in the traditionalist camp that believes we have an obligation to introduce our students (referring to the larger universe of those we teach) to the great human conversation, and open doors to a world of endless possibilities. So what do we really need to teach in the residencies that will last beyond the passing of boards? Let me suggest three code-breaking skills which should be taught to residents and carried throughout their careers.
The first essential tool is mathematics. Differential and integral calculus, fractal mathematics and number theory are not, for our purposes, as important to physicians as statistical analysis of data. As simple a concept as number-needed-to-treat or incidence-of-disease-in-a-population are frequently not well taught or understood; and yet these are the very skills which separate physicians from technicians. The PAs I have worked with can all close wounds, perform spinal taps and reduce shoulders. It is at the judgment and analysis level that we need to make “How” questions subservient. Current knowledge is perfidious at best. The language of science is mathematics and it is how we speak to each other in as close to an unbiased way as possible.
The second code we must teach them to break is language. The more precise the language, the better the communication. Words have meaning. These words mean different things to different specialists. The term “fundus” means something entirely different to an ophthalmologist than it does to a gynecologist. The emergency physician must be able to communicate to all the various specialists on their terms. This is an absolute. You never talk to an internist about an orthopedic problem. The average internist doesn’t know a Galeazzi fracture from a Monteggia fracture. Likewise, most orthopedists don’t want to hear about a short PR interval. They believe the only function of the heart is to pump blood and antibiotics to the bones.
But we always deal with other specialties on their turf. They judge an emergency physician by their diagnostic acumen and language precision. We should not allow a resident to speak to a neurologist about a patient and use the term “dizzy.” Vertigo, near syncope, multi-sensory deficit syndrome, and ill-defined light-headedness are all described under the large umbrella term as dizzy, and yet are completely different disease categories with totally different differential diagnoses. The cogent discussion is key to the success of emergency medicine.
The last code our residents need to break is the social code. What do other doctors say to each other? How do intelligent, thoughtful physicians behave toward patients, family and staff? We teach these social code lessons mostly by the way we ourselves act and how we expect our residents to act. People run on the track at the speed that we expect. If you expect excellence, you get excellence. And that has to do with not only scientific knowledge but social behavior. As the twig is bent, so grows the tree.
To tolerate less than excellent conduct from all parties is to cheat the young out of the skill set they will need to be a success and a leader in the profession. We are more judged by what we do than what we tell others to do. The quid pro quo is simple: From the excellence we provide, excellence will be shown by those we command. Each of us is a social transmitter sending out signals of acceptance/rejection, respect/disrespect, approval/disapproval with every word or action we perform. Everyone is watching the behavior of the attending physician. Clues to how they can behave, be it resident, PA, nurse or tech, is determined by how the “boss doctor” handles the situation.
The job of educating residents is to find that unique “sweet spot” where we can gently assure a stream of current scientific knowledge blends with moral and social values which are often given short shrift in the heat of battle. Our job is to reveal the world as it is, not as they imagine it to be. I have become the scourge of postmodernists, relativists and other anti-realists who would replace this world with realities of their own making.
We must avoid soporific degeneration into sloppy sentimentality, building the shell of self-protection which stops many an experienced emergency provider from feeling another human’s sorrow and pain. The careful comforting of a young family that has just lost a child teaches more to a resident than your impromptu lectures on Thalamic lesions ever will. There is a fine line between confidence and hubris, which is the hallmark and centerpiece of an emergency physician’s life. To not teach this is to not teach anything.
The quality of life debate goes on ad infinitum. Like Nietzsche and Tolstoy, I categorically reject and am a staunch critic of the mass production of human beings. A 95 percent board score is desirable. A resident with a 94 percent board score and a director vouching that he or she is brilliant at handling patients is even better. Knowing when to treat aggressively and knowing when to back away and let nature proceed is where our teaching needs to be. In the infinite timeline of the universe, does existing with a pulse in pain and misery for one more month really matter?
Life is brought into balance when we understand that meaningful lives exist on the razor’s edge. Our real job is to teach the young that the greatest fulfillment exists at the intersection of holding on and letting go. Every day, in the vast abyss of medical knowledge, we must keep a few things of scientific importance in mind to define who we are and what we know as fact. But we must let go of those things which clutter our lives and inhibit our real flourishing (in the Aristotelian sense). The most important thing we can teach the young to let go of is senseless anger. It diminishes both them and the medical experience. The most important thing we can teach them to keep is that small voice inside them that says that: “We are doing things well, but we can do them better. There may be a better way.” Without that voice, they are condemned to repeat the mistakes of the past. “I want to make it better” should be their motto.
Have I made mistakes in mentoring the young? I have made every mistake possible. I could have been a better example – kinder, smarter, more willing to forgive and less willing to be a critic. But I’m going to try to be better at this impossible task. It is the trying, I think, which is just as important as the destination.
“Ad astra per aspera.”