5 Things I've Learned about Medical Education from the Perspective of Educators

Over 20 clinician educators reached out to me privately in February 2024 after a fruitful online discussion about medical education. They shared their perspective on MedEd, the recent @NEJM podcast episode on the topic of wellness days as well as corrected my still very limited perspective of the dynamics of medical education.

These are not new concepts, just new to me.

Here are the 5 things I’ve learned about medical education from the perspective of educators:

1. They love teaching students and trainees so much, and the employment path to that end needs to be preserved carefully.

• They readily give up the higher income of private practice and the prestige that the research path in academia offers, because they just want to teach. As much as these sacrifices may be, holding on to this role is not easy. Many would love to fill these positions. Blinded evaluations from students do have an impact on whether they’ll continue to receive the educator role FTE, though most of them say that, as long as they are treating students and trainees as colleagues, they’re not worried about negative trainee evals. One caveat to this is that if educational leadership has shown a propensity to lack the courage to fully understand and investigate an issue, the teachers don’t feel as secure since a knee jerk reaction to a complaint could result in loss of privileges, warranted or not. It was mentioned that academic physician attrition rates were 50% after 5 years of work, this data coming from 5+ years ago. Reporting on such things no longer exists apparently, but they said it would not be surprising if it was worse now. These people love their work, but it’s extremely stressful. One thing I was wrong about is the impact that healthcare institutions and admins can have on whether a given physician continues to receive such FTE from educational leadership. They are largely siloed from each other. Not that they aren’t interrelated, which leads to my next point.

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2. Educators struggle with how to balance advocating for better support for trainees and advocating for pursuing excellence/high standards in patient care in the public arena.

• On a one-on-one basis, they are keen to know their students as well as possible. If the student’s cup is fairly empty, and they’re eager to fill it, they want to encourage that, giving them as much to learn and practice as possible. When they are struggling, it should be fairly obvious. And almost all of them said that they think the field of medicine needs to be a kinder profession. If someone struggling is given the chance to reset, chances are, they’ll come back, better prepared to become a great physician. And more importantly, they will be healthy and more content. But they also said that there is a very minute subset of students who are unable or unwilling to put in the effort needed to become doctors. When they fail to meet the standards, they then blame the system for not supporting them. The distinction between this rare type of person, and the more common genuinely struggling person who just needs some space and time to reset is obvious to the teachers if they are paying attention. But as far as any sort of public statements, they have to be far more cautious. I found this point to be well confirmed when I came to find that a clinical educator that I had been communicating with online this past weekend had deleted their account. Nothing strongly opinionated was even said by this person, but clearly public statements can have a deep impact, and the teachers are concerned about that. Saying things like “wellness days are ruining the quality of education” or on the other hand “physicians in training deserve better support” can result in different, but equally negative outcomes for them. If they put down wellness days, it could cause them to fall out a favor with educational leadership and jeopardize their teaching role. Or if they speak up about how residents need to be better supported, limit scut work, etc. they jeopardize any path they might have on the admin side to actually effect change for trainees. Going viral is the last thing they want. The reason is more complicated than desire to preserve their own own jobs. It has to do with trust, which leads me to the next point.

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3. They value the trust of their students.

• Building and maintaining trust between teacher and student is of great value to them. They have a limited window to teach really important topics and skills. They want to make the very most of it. Publicly saying something even remotely against resident advocacy, perhaps pointing to a specific anecdotal example where one of an extremely few (percentage-wise) trainees abuses the intent of the time off, wellness day offerings would only lead to a negative outcome as far as trust is concerned. If they were to say such things, any current or future students would read that now, or in the future, and it would be so much more difficult to earn their trust. The far majority of students and trainees are here to learn, and the teachers know this. But the students individually may lose confidence that a given educator believes in them and will genuinely support them if they were to see a that person openly discuss these relatively few unwilling learners. So the teachers stay silent in the public forum to save for the opportunity to show the trainees who they really are in person. Building and maintaining trust from their students is among most important achievements clinician educators wish to have. From a macro-level, same thing goes for PDs. Any public polarizing statements are a non-starter as real or perceived insensitivity could be devastating for the match. These educators who want to fully support trainees - they’re largely unable to make public comments on these topics. For the same reasons mentioned in point 1, they publicly remain fairly neutral.  I’m sure on an individual level, many trainees get to know who the supportive educators are.

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4. Educators know that the training time period is a short term but huge value that many take full advantage of, some don’t appreciate, and some are more limited in taking full advantage of it.

• The concept that a now attending physician would never say that “they wish that they had seen fewer patients” is a highly polarizing statement. This idealistic statement highlights how one can learn extensively and practice without liability or legal repercussions, while also effectively ignoring the reality that every single person learns differently and brings varied energy. Some have mentioned the concept of CBTVME (competency, based time variable medical education) could be the most adaptive way to work with a huge number of people with a wide variety of trajectories, motivation, and current energy level. They ideally want everyone to have access to the value of this time. While none of these educators represented themselves as thinking that everyone needs to buckle down and just push through, they did say that there are a lot of educators like that. They said that abusive programs are out there, and that needs to change. Also, it’s obvious to me that anyone who would take this more old guard approach would be extremely unlikely to contact me. In today’s environment, it’s becoming rare for someone to publicly say that they love their work more than anything, that they want to blow past duty hour limits because they want to do all they can to learn while they can. But many of the educators who contacted me said that they know who these people exist, they know who they are, and nurture them in line with what they personally want to accomplish to the degree that they (the educators) ethically can. Last point on this topic is that a few educators said that there needs to be better communication about the trauma all physicians bear due to the psychological, emotional and moral impact. Hours worked, and subsequent opportunity for rest variability is a key, but it may not lessen the weight that one carries. But because hours are measurable, and, in comparison with other factors in medicine that can cause trauma, is relatively easy to change, it gets a lot of attention. To meaningfully support trainees as they take on their own practices in due time, addressing such trauma by means of mental health support, reducing non-education related work at the hospital AND giving trainees the days they need to function as a human are all critical.

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5. More than half think centering discussion on how to reasonably pursue excellence while maintaining a high standard of patient care is the right way to approach trainee well-being.

• Not all of them said this, but more than a half expressed disappointment with how most educator-initiated public discussions, including the recent one on the @nejm podcast, center on the relationship between what residents/students are asking for and the resulting quality of training. A few mentioned that this approach is exacerbated by the not uncommon concern from educators that the graduating med school classes who were sidelined by the pandemic early on are a little behind in experience and so the trainees requests for time off fall on ears that are already worried they’re behind. And the trainees know this is in the air too. Hyperfocusing on this dynamic may cause discussion, but not the productive kind. They also bristle at the continued use of “teenager” and other infantilizing terms. Not only is it inaccurate, it alienates a huge portion of those who need to be engaged for any productive conversation to be had. Senior physicians thinking these are endearing terms need to wake up if they want a shot at meaningful change.

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This is my current, albeit a rough draft, understanding of some of the challenges in medical education. For the sake of refinement and accuracy, I welcome your feedback.

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