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The art of teaching

Autumn heralds the re-opening of schools and colleges and the return of students to academic pursuits.  School books may have been replaced by brightly covered iPads, but uniforms, buses, and school bags are still evident in every town and village throughout Ireland, and railway stations bustle on Sunday evenings with enthusiastic scholars returning to their educational establishments.

GP practices are not considered institutes of education. They do not observe term times, contain lecture theatres, or issue degrees. Yet, the word ‘doctor’ derives from the Latin ‘docere’, which means ‘to teach’ and teaching is one of the core duties and responsibilities taken on by many GPs, despite never having received any formal training in this skill. 

William Osler, a famous doctor and teacher in the 19th century stated: “I desire no other epitaph… than the statement that I taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do.”

 Osler was the first doctor to leave the lecture theatre and bring teaching to the bedside, believing that, “to study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all”. He did, however, also believe that specialists were the best teachers. GPs, on the other hand, were considered affable and understanding individuals who replaced their lack of knowledge with kindness and warmth and who held your hand while you suffered and died.

These stereotypes still flourish today. Roger Neighbour’s latest book, The Inner Physician – Why and How to Practise ‘Big Picture Medicine’, describes a study carried out with a group of newly qualified doctors, asking then to record their assumptions about GPs and specialists. “Cardigans, tree huggers, hospital drop-outs, lots of time off” were some of the more flattering descriptions offered for GPs. “Expensive cars, high prestige, poor communication,” were some of those attributed to specialists. 

‘It is by watching skilled practitioners and then practising those skills with real patients that one first experiences what it is to be a doctor’

Despite this, medical educators have long since recognised the value of general practice as an educational environment for aspiring young doctors. University of Limerick’s Graduate Entry Medical Programme includes an 18-week placement in general practice. Registrars on GP training programmes spend two of their four years in practice with an assigned trainer. Many of these teachers will have higher diplomas, certificates, and Master’s degrees in medical education, but these are not necessary requirements to be an effective GP teacher. 

GPs who wish to add teaching to their skills repertoire can doubt their ability to teach, thinking that as they may have temporarily forgotten the intricacies of the Krebs cycle, the branches of the internal carotid artery, or the precise dermatomal pattern of the upper limb, they have very little to offer aspiring doctors. But this knowledge has never been more accessible than nowadays and can be easily retrieved from text books, journal articles, and even YouTube. Teaching the art of medicine alongside the science is the main strength of GP teaching. It is by watching skilled practitioners and then practising those skills with real patients that one first experiences what it is to be a doctor. Breaking bad news, comforting the bereaved, recognising the acutely ill child while they are still in the waiting room, deciding which headache needs referral amidst the four or five you have seen that day – these skills can only be acquired through the practise of medicine every day in a safe and supportive environment. This is what GP practices provide for students and registrars. 

Every doctor requires a good knowledge base, but it is the application of this knowledge to Mrs Brown’s back pain, Mr Smith’s raised PSA, or Mrs O’Dwyer’s fear of cancer that requires the greatest cognitive effort and the skilled guidance of the experienced doctor with years of accumulated wisdom and knowledge. 

The best teachers are not necessarily those who assess levels of knowledge with carefully constructed, validated tests. They do not resort to the tactics of belittling students in front of peers or patients. They do not expect their pupils to know everything. They simply allow the aspiring young doctors into their inner sanctum, demonstrating humility, uncertainty, and a genuine sense of caring for each patient they encounter, while skillfully applying the relevant knowledge. They allow their pupils to question freely, challenge perceived wisdom, re-appraise and re-evaluate their understanding, confident in the knowledge that this grand collage of medial information will forever remain incomplete, both for teacher and pupil. They approach every patient encounter with, what the Buddhists call ‘beginner’s mind’, a willingness to learn a new lesson from each one. Universities may be the centres of knowledge but the apprentice develops wisdom under the watchful eye of the experienced master among the people they care for — the patients.

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