There are moments as a teacher when I'm conscious that I'm trotting out the same exact phrase my Professor used with me years ago. It's an eerie feeling, as if my old mentor is not just in the room, but in my shoes, using me as his mouthpiece. It happened yesterday when I was at the bedside, showing my students how to feel a patient's spleen which happened to be quite enlarged.
Anyone can feel a big liver. Sitting as it does under the right lower ribs, the liver when it enlarges isn't shy and makes itself known to even the most amateurish of probers. But the swollen spleen is more elusive. It is set back deep in the belly, under the left rib cage; it has to be three times its normal size to be felt, and even then it often lacks a distinct edge and is easily missed by the inexperienced examiner.
As a student I couldn't convince myself that I'd felt the spleen, even when it was known to be massively enlarged. I began to doubt myself. One day my teacher, his hands on the patient's belly, had me lay my fingers over his fingers. Then he slid his fingers out from under mine, instructing me not to budge. "Don't try to palpate the spleen, but instead let the spleen come and palpate your fingers! Don't dig! There is no gold there." As the patient took a deep breath, her diaphragm contracted and pushed the spleen down and my waiting fingers felt a gentle nudge, like a whale bumping into a boat. Let the spleen come to your fingers! It was a brilliant pearl of his own invention. For me it was an extraordinary moment, a breakthrough. It was as if he'd put himself in my shoes, anticipated the difficulty and also shared mydelight in success.
I was around my mentor for two more years, enough to hear him trot out Don't dig! There is no gold several more times to other students. I was disappointed at first, as if such repetition took away from what I had felt to be a unique, brilliant moment, one that was somehow mine and his alone.
It's taken all these years, for me to understand how special a teacher he is. Every single time he said the phrase, he did so with such intensity, enthusiasm, as if it were the very first time those words came out of his lips. It wasn't. . . but the point is, he knew that for me it was the very first time.
Perhaps that's the secret of being a good teacher, and it is why I aspire to be like him. I have to keep in mind that as repetitive as my teaching can seem to my ears, for the student, it is the very first time. And therefore I have to make sure that I bring my all to what might be a seminal moment for the student.
The reward of course is what I saw yesterday as I guided my student's fingers to feel the spleen. When she looked up I knew she'd felt it. Perhaps one day, she will say to a young medical student, "Let the spleen palpate your fingers, and not the other way around. Don't dig, there is no gold." And then the chain will remain unbroken.
Let me hear from you teachers and students out there, but I'll contend that that is as close as we get to immortality.
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Abraham Verghese
Having also learned from the same Master Clinician, I too remember these pearls: "People are better witnesses of the urine that they pass than the sputum that they spit.” And your favorite and mine: "Percuss to feel and not to hear." How amazing that is. Thirty years and counting and we still strive to achieve that perfection in the art of percussion. I still don't know that I will ever feel, I mean really feel... And then, each time I think of the hypoglossal or assess for dysarthria and want to test fine motor control of the tongue and lips, I instinctively say to myself "kadaloruthil ural ullargirathu". "Sollu paarkalaam?" he would say to the Tamil-speaking patient. How do I test for such tongue movements in the English? Will I ever be that good? Will I ever feel confident in living by Palfrey's Law at the bedside? (after Francis W. Palfrey, b1877, Visiting Physician, Boston City Hospital): "When the laboratory data or radiological tests are in conflict with your clinical judgment, trust your clinical judgment."
Passing on of the teaching phrase - the perfect verbal nugget - is a wonderful process, yes. But I also note in your account another episodic element in teaching that is equally magical, though often less crisp and quotable: the redirection of students' attention from where they think the action is, to the true wellspring of sensation that will correctly inform them. Your teacher's sliding his hand out from under yours at just the right moment.
In another arena of technique transmitted by tradition and example: last summer a guitar teacher named Mitch Corbin gave me the precious gift of just such a redirection of my attention in my playing. We were working on tone. "Don't listen," he instructed. "By the time you have struck the note, it's too late. *Feel* the moment the pick touches and pulls off the string - that's where you need your awareness to be sharp."
It made all the difference.
medicine is a subject that should be full of wonder, so its always struck me as strange how few of its teachers can convey that wonder through their actions and words - maybe bringing that feeling out in someone else is harder for them than sparking it inside themselves, or maybe something in the practice of medicine grinds the capability out of them at some point. i don't know. i suppose i'll figure it out myself one day.
all i know is that there are few experiences more rewarding than learning from a doctor who truly understands this core truth and knows how to channel its power. but i guess that's true for a teacher in any field.
"Don't ask whether a kid has a bicycle helmet. Ask what color his helmet is." A teaching point - how to avoid eliciting the "right" but untrue answer - that has stayed with me for years. The preceptor who shared this pearl long ago now works alongside me in clinic. When she recently heard me sharing her approach with a trainee, I reminded her, "You taught me that one, Penny." She was surprised - "Did I really?". I couldn't believe she didn't remember. Though it's a minor point - less glamorous than advice for finding a spleen - it has stuck with me - had a lasting impact - without my teacher ever suspecting. Immortality - without knowing it.
We send teaching points flying out like seeds from a pine cone. Who knows where they'll land, stick, grow?