Tinsley Harrison Internal Medicine Residency Program                        Excellence Without Ego

Essays by the Alumni: "Occult Learning" by John I Kennedy Jr

MyBoys3Think about your training at UAB.  You will probably recall gifted teachers and skilled clinicians, people who dazzled you with their breadth of knowledge, technical skills and diagnostic acumen.  With a little more reflection, however, you might sense that there was much more that contributed to your professional development. The concept of the "hidden curriculum" has received much attention in medical education circles, and there is no doubt that a lot of acculturation occurs during the transition from layperson to physician.1,2  There are substantial negative connotations associated with this notion of the hidden curriculum and we would do well to examine carefully the counter-productive aspects of medical culture and tradition that we mindlessly propagate.  On the other hand, there may be useful, even formative, learning experiences that come about not as the result of overt efforts but rather by serendipity.

A number of years ago my family spent the larger portion of a summer in Japan where I was the visiting professor in a residency program.  We learned from one of our hosts about a Japanese aphorism (kodomo wa oya no senaka o mite sodatsu) which states that "your children learn from your back."  The curious wording of the English translation caused it to take root, and our friend explained the meaning: parental lectures are largely useless, but the examples that parents set, particularly when they are not conscious of being observed, have a profound impact on their offspring.  Sage parents may recognize this to be true, but it is a daunting concept that has haunted me since.  As I considered this idea in the context of child-rearing it occurred to me that it applies in other domains as well, including medical education.  I thought about the many occasions when I learned something of great value without anyone making a premeditated effort to teach me.  I realized that I have been the beneficiary of "occult learning."


One of my earliest encounters with the occult occurred on a Sunday during my second year of residency training. We were rounding with the specialist assigned to cover the service for the weekend, and as we prepared to leave a patient's room, he asked the patient, "Do you need anything?"  I had heard this question posed many times previously, and had filed it away as a useful tool to create a natural transition for closure of the encounter.  On occasion I had seen an attending physician stop by the nurses' station to relay a patient's request, but at least as often we simply moved on to the next task with the assumption that someone else would address the need.  However, this occasion was profoundly different.  The patient asked for some water.  Our attending grabbed the small styrofoam jug from the bedside table as we exited the room.  He proceeded to the alcove down the hall where he filled it with ice and water and then returned it to the patient.   For this senior faculty member, it seemed to be the most natural and insignificant occurrence of the day.  Nothing was said by anyone about the event, but I felt as though I had been struck by a sledge hammer.  I immediately thought of all the times I had rushed along with my very important business and had failed to attend to someone's basic needs.  This simple act demonstrated in the most powerful way that no need is too trivial for the doctor's attention and that such small acts of service are not demeaning but, in fact, are sustaining and fulfilling.  They cement the human bond that must exist in a therapeutic relationship.  This same specialist also took the time to teach us a number of important medical facts that weekend, but the one thing I remember is that simple act of kindness.

Occult learning is not only clandestine, it is also multidirectional.  The teacher regularly learns from the student.  Perhaps that is why some of us cling to the academic environment.  Near the mid-point of my final year of residency, I was working with one of the better interns in the program on the same general medical service where I had begun my internship.  I was entering that very satisfying stage of training where I had amassed sufficient experience to be confident with most common medical problems and to know where and how to solicit help when needed.  My learning trajectory had begun to plateau, or so I thought.  Late one evening when we were on call, I was passing through the ward to make sure all was quiet before heading upstairs to the call room.  As I walked down the hall I was surprised to find my intern colleague in the room of an elderly patient who had presented several days earlier with altered mental status.  I stopped in to see what was going on and found him in the midst of repeating the complete physical exam that he had performed on the day of the patient's hospital admission.  He told me that he felt that we lacked a complete understanding of what was wrong with this particular patient and thought that, perhaps, if he did a detailed evaluation again that he might understand the problem better.  That night he noted some resolving skin lesions that we had discounted on the initial exam, and a subsequent biopsy led us to the diagnosis of Rocky Mountain Spotted Fever.  I knew at the time that I had witnessed something important, but did not fully appreciate its nature.  Years later, when I learned about the concepts of intuitive versus analytic thinking as they apply to diagnostic reasoning, I realized that my young colleague had taught me about it years before.  More importantly, he had given me an intuitive understanding of the importance of making a conscious shift to analytic thinking in complex or uncertain clinical scenarios.  The importance of this concept is illustrated by the fact that it is a central component in the body of work for which psychologist Daniel Kahneman won the Nobel Prize in Economics in 2002.3

Scattered about UAB are portraits and sculptures of famous physicians and revered teachers, the people we consider to be role models for our profession.  However, we occasionally learn from someone we do not hold in such high regard.  In the television series, House, Hugh Laurie portrays a drug-addicted sociopath who happens to be a brilliant diagnostician.  Most of us would quickly point out the many unrealistic aspects of medicine as depicted in this series, and we would like to deny that any real physician could behave in the manner of Dr. Gregory House.  But we all know someone who is extremely bright and/or technically gifted but lacks interpersonal skills and social graces.  I recall such a person from my years of training. He was a remarkable repository of medical information, but on his best days he was cold and distant and on occasion he was openly arrogant and confrontational.  I found it particularly annoying that when it came to complex clinical problems, he was almost always right.  Even more vexing was the fact that I seemed to run into him everywhere I went in the hospital, in the radiology department, the lab, the heart station, etc.  One afternoon during my first month of pulmonary fellowship I made my way to the surgical pathology suite to look at a biopsy I had done the day before.  When I arrived at the pathologist's office this most annoying physician was walking out the door.  I was very surprised to see him there and asked him what he was doing.  He looked at me with some disdain and replied that he was reviewing the lung biopsy on his patient, the biopsy that I had performed.  I had never imagined that anyone other than a pulmonologist, or perhaps an exceptional thoracic surgeon, would actually take time to look at a lung biopsy.  I thought about this for the remainder of the day, and began to realize that the reason I ran into this fellow so regularly was because he made a point to look at every biopsy, every x-ray, every test, and to discuss it in excruciating detail with the relevant expert in that area.  Even though I found him annoying and offensive, he taught me the importance of examining the primary source data and avoiding reliance on second hand information.  I am certain that I have avoided many mistakes as a result of this lesson.

Dante Alighieri had only a few encounters with Beatrice Portinari and reportedly never even spoke to her.4  Nonetheless, Dante was obsessed with Beatrice and she became the muse for all of his famous poetry.  Scholars indicate that she was unaware of her influence on one of the most famous writers of all time.  Most teachers yearn for feedback from the learner that the lesson has been received, understood and appreciated.  Yet it seems to me that a great deal of teaching and learning is unplanned, unrecognized, undetected.  It is occult.  Each of these three individuals taught me something that has stayed with me throughout my career, but none of them knows.  Somewhere out there, someone is learning from your back. Be careful.

References:

1. Hafferty FW, Franks R.  The hidden curriculum, ethics teaching, and the structure of medical education.  Acad Med 1994; 69:861-71.

2.  Chen PW.  The hidden curriculum of medical school.  New York Times January 29, 2009.

3.  Kahneman, D.  Thinking, fast and slow.  New York: Farrar, Straus and Giroux 2001.

4.  "Dante - Introduction." Poetry Criticism. Ed. Carol T. Gaffke, Anna Sheets. Vol. 21. Gale Cengage, 1998. eNotes.com. 12 Nov, 2012. http://www.enotes.com/dante-criticism/dante/introduction


John Kennedy is a native Texan who has lived more than half his years in the city of Birmingham.   On most days he spends the pre-dawn hours running through the streets of the adjacent Tiny Kingdom.  His wife, Linda, continues her work at AT&T when she is not reading the world’s great books.  Linda and John have entered the empty nest phase of family life; Trey (25) is an episcopal postulant currently working at St Peter’s Cathedral in Helena, MT, and Walker (20) is a sophomore at Bowdoin College in Brunswick, ME.   John is grateful to the UAB Tinsley Harrison Internal Medicine Residency Program for transforming him from MD to RD (real doctor.)