Today's guest column is by Anthony L. Suchman, Assistant Professor of Medicine and Psychiatry, University of Rochester, and Director of the General Medicine Unit at Highland Hospital, Rochester, New York. A longer version originally appeared in Medical Encounter, vol. 7, no. I, Spring 1990.
I recently visited my daughter's third-grade class to tell them something about what it's like to be a doctor. I had no idea what to do, so I reverted to familiar ground and conducted a workshop on medical interviewing. Instead of lecturing them, I would let them feel for themselves what it's like to do what a doctor does.
Their teacher (a very good sport) played the role of a patient who had a stomach ache. One by one, the children put on my white coat and interviewed the patient.
The first student asked the patient if he had eaten lunch. When I asked him why he asked that question, he responded that the patient might have eaten too much food. The second student asked whether the patient was under any stress. His hypothesis was obvious. Other students asked the man if he had eaten anything unusual, been injured, or had a history of lactose intolerance.
I was impressed by the sophistication of the third-graders' hypotheses, but even more striking was that the children almost universally asked very focused, hypothesis-based questions.
After a while, I pointed out how hard they were having to work, and suggested that they simply asked him "what happened?" they might learn quickly which questions were useful and which ones were off target. This led the patient to relate the story of how his stomach ache came on shortly after eating in a restaurant, which the students followed with questions about what the patient had eaten. When I then invited a student to ask if anyone else got sick, the response led the class immediately to tainted tuna fish as the offending agent.
The teacher asked if the class wanted to try another case. All the hands went up. The teacher and I conferred briefly and decided that he would have a headache brought on by stress. The first student approached the "patient" eagerly and asked, "Do you have any allergies?"
"Wait a minute," I protested. "You don't even know what's wrong with him."
"Oh yeah. What's wrong?"
Out came a very sad story of a teacher who'd been informed that he would not have a job come fall. And from the students, out came more hypothesis testing.
The third questioner was a girl who had proposed during the opening discussion about what doctors do that doctors talked with people about their problems. After she, too, asked a hypothesis-testing question, I told her about the so-called "three-function model" of medical interviewing (1. figure out what's going on, 2. care about the patient, 3. decide with the patient what to do) and asked her to say something to the patient that would show him she cared about him. She reassured him that although he faced some difficult problems, in time they would get better. The beauty and sensitivity of her words astonished and moved me.
The next student volunteered a diagnosis: depression. We all brainstormed about what it might feel like to be depressed in order to generate questions to test that idea. And so it went until the last student strode confidently to the front of the room and declared that the patient's headaches resulted from stress and advised him to rest.
Leaving the class, I was filled with thoughts. These third-grade students interviewed just like doctors: forming and testing hypotheses before hearing the story, based on the first sentence, even without the first sentence, in one instance.
What is it about testing ideas -- trying to get the right answer -- that is so compelling? Curiosity? Maybe, but one would gather more new information with broad, qualitative inquiry. Conditioning? These children have spent nearly four years in an environment that places a premium on right answers. How can we encourage students to leave the safety of right answers and relish the unknown and unexpected?
I was struck by another aspect of the students' questioning: Here was a group of interviewers who found the content of the story and the process of problem solving so compelling that it did not spontaneously occur to them to respond to the second patient's emotional distress. When I have seen this same phenomenon with medical students and residents, I attributed it to the lack of balance in their medical education. Watching this behavior in third graders made me wonder if there is not a broader, culturally determined tendency at work: valuing things over people, ideas over feelings, mind over soul.
And finally, I wondered what it means that the information processing strategies of many adult physicians scarcely differ from those of 8-year-olds. This reflects very well on the third graders, but it raises questions about the adults. The problems that we address in teaching interviewing begin well before medical school.
I am grateful to this third-grade class for prodding me to think more deeply about the roots of the system of medicine which we are trying to change. I hope that a number of those students will want to become doctors. But not the one who asked me eagerly if most doctors made more than $100,000 a year -- I encouraged him to go into business.