Friday Reflection 37: Why I Teach (acceptable and less acceptable reasons)

PF is a 72-year-old man with heart failure with preserved ejection fraction. He has been doing well but has noticed worsening exercise tolerance. His other medical problems are hypertension, atrial fibrillation, and diabetes. He currently takes rivaroxaban, atorvastatin, metformin, losartan, and spironolactone. He is seeing his general internist who suggests initiating therapy with empagliflozin.

Although this patient sounds like someone who would see me at 4:40 on Friday afternoon, he is completely made up. He was created to set the stage for the discussion of a recent NEJM article in the course “Critical Appraisal of the Landmark Medical Literature.”

I planned that February, my 25^th year teaching this critical appraisal course to our fourth-year medical students, would be my last. Twenty-five years is a very long time to do anything. In 2002, I gave the courses case control study lecture having had no sleep, four hours after my first child was born.^[1] That child is now a senior in college. In 2022, I gave up didactic teaching and administrative roles in our medical school, so it made sense that I would soon step away from this course. I recognized that I would no longer know the students and I worried that my teaching was getting stale.

Midway through the month, however, I had second thoughts. During the hemming and hawing that followed, I reflected on the reasons I have been committed to medical education in general and to this course in particular. Some of the reasons are admirable but not terribly novel. Others are a bit hard to admit, but just as true.

First, a little about the course.

As a resident I fell in love with evidence-based medicine and critical appraisal. EBM made medicine seem, for the first time, like something I might be able to grasp. As a budding generalist, I could see specializing in critical appraisal. I also had some amazing teachers during my residency. David Rind, who has written for Sensible Medicine, and Mary Beth Hamel were two particularly memorable ones.

Before finishing residency, I began to formulate a course based on JAMA’s Users’ Guides to the Medical Literature. The course would teach students to read the studies by dissecting some classic articles. Soon after arriving in Chicago, I created the course with a friend and colleague and then taught and adapted it over decades. Because of the course, February has always been the high point of my teaching schedule.

So why did I teach this course for so long? First, the admirable and uninteresting reasons.

Every teacher will probably tell you the same thing about why they teach. It is exciting and absurdly rewarding to watch people learn and know that you have had some role in their success. This might be particularly true when you are teaching them to care for others.

While teaching, I love watching people try out their new knowledge. In the Critical Appraisal class, this meant students vigorously arguing for and against adopting the practices researched in the articles we read. The course ran just as match lists were being submitted, so the students were newly differentiated. I particularly enjoyed it when, say, a budding orthopedist would present a “landmark” article in her field, only to be forced to defend it against the withering attack of a future pediatrician.

I am also, perhaps pathologically, committed to the practice of good medicine. I love the idea of teaching that to the next generation. Getting to instruct smart, driven, altruistic, mostly twenty-somethings how to practice and stay current during their careers felt like a gift.

However, nobody does anything for long for completely selfless reasons. I stuck with my teaching for reasons that are a little harder to admit.

When I started the course, I had a lot of grand pedagogical ideas. The syllabus states: During medical school, most knowledge is gleaned from textbooks, review articles, and lectures. During the reminder of a medical career, continuing education depends on learning from cases and assimilating new data as it appears in the medical literature. This course will refine your critical appraisal skills while providing some foundational knowledge of the medical literature.

But I also needed “to pay the bills.” My initial contract dictated eight half-days of clinic each week. I needed to find funding to support my time if I was going to develop an academic career. It was easier to beg for money from the medical school than from the NIH. Developing and teaching a “selective,” a required elective that fulfilled a requirement that students take courses in their fourth year that revisited the preclinical sciences, got me some protected time. 

After beginning this course, I realized the pleasure of 90 minutes -- three days a week, for an entire month -- being set aside for often vigorous, thoughtful, opinionated conversation. The course was like hosting a salon. Notable was that the conversation was always about topics that I had chosen and knew more about than anyone else in the room. Let’s just say that this never happens at a dinner party.

The dark side of my altruistic desire to assure that good medical care persists is the understanding that I should dictate what that “good medical care” is. I tend toward a skeptical, minimalist, conservative approach to doctoring. This puts me in the minority in the world of academic medicine. This course became my opportunity to attempt a brainwashing of the students.

It took only a few years for me to realize that this course churned out future colleagues. It was not unusual that a student would leave the course comfortable enough with me to stay in touch. Many of these students have since lapped me in their academic careers. It has been a treat to watch their trajectory, to gather in a bit of their reflected glow, to get to have an occasional coffee with them, and co-author a paper or two. The course itself fills a couple of lines on my CV; the collaborations it led to fill pages.

Then there is a fact that any teacher will admit, though maybe only after a beer or two. Some of the joy of teaching is the admiration of students. Until the last five years, this course was not a required part of any student’s degree program. Thus, there was a good bit of sampling bias in those who registered for it. All the students in the class knew me, thought they could tolerate another 18 hours of me, and were interested in the material we would cover. Reading course evaluations written by these students -- a few of whom would argue that the course should be required or that it was the highlight of their medical school experience -- was pretty addictive.

And then, it is just nice to hang out with young people and be reminded of a time of potential and future adventures.

In the end, I decided that twenty-five years was enough. I will miss the students, the enriching conversation, and the occasional ego boost. I think I can probably survive without it. I plan to publish the syllabus on Sensible Medicine, little by little, over the next few months. I hope this will be an efficient way to educate/brainwash a wider population.

Addendum: The day after the final session of the course, I met with a first-year student who is working with me in clinic. During our meeting he asked, “You seem to be really interested in critical appraisal. How would a student really learn that skill?” I wondered if he was trolling me.

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^[1] My son and my wife were sound asleep, having had an active night. I was still riding an adrenaline high, so I figured, why not give the lecture. I remember the talk not being very cogent.

Photo by Immo Wegmann