We Are All Teachers

During my early years of attending AAHPM board meetings in the late 1990s, there was talk of separating “academic” from “clinical” conference presentations and workshops. James Cleary, MD, president of AAHPM at the time was skeptical of this discussion because he said “We are all teachers. Everyone in this room is a teacher.” And you know something, he was right. Every member of the interdisciplinary team is a teacher and we all have much to teach fellow healthcare providers, patients, families and caregivers, policy makers, and politicians about the principles and science of our field.

We will soon experience tremendous shortages of healthcare professionals as the geriatric tsunami approaches. Already busy healthcare providers will get even busier. One of the consequences of being overwhelmed is that people stop thinking and rely on things such as checklists. Now I do not have a problem with responsibly used checklists. Atul Gawande, MD, a surgeon well known in the popular press and a supporter of our field, wrote a book, The Checklist Manifesto. In his book he talks about how checklists improve health outcomes and most of us are familiar with checklists used in operating rooms.

Ironically government and third party payers have jumped on the bandwagon by wanting to tie reimbursement to quality and measuring quality by monitoring checklists. Unfortunately, as the following story demonstrates, quality in medicine is not always captured by checking off a box.

Mrs. Jones was a 69-year-old woman enrolled in a hospice homecare program with stage IV lung cancer. Unbeknownst to her hospice team, she went to see her primary care provider for a regular check on her diabetes. While still ambulatory, she was very debilitated and needed a lot of assistance. In the office, her provider noticed that she was “overdue” for her screening mammogram and one was scheduled. She received a call from her provider telling her that the mammogram showed a mass and she needed to see a surgeon for a biopsy. An outpatient biopsy was done and it showed malignant cells. She was referred to the oncologist who had treated her for her lung cancer. When I learned of this situation, I called her oncologist, Dr. Gardner. Fortunately, Dr. Gardner was looking at Mrs. Jones in the context of her overall medical condition. She had a long discussion with Mrs. Jones and her husband and did not recommend any disease-modifying treatments for her asymptomatic breast cancer. When I made a comment that I wished that the mammogram had never been ordered, she said, “Well you know, someone was just checking off a box somewhere.” We need to be there to teach the people who are filling out the checklists and the administrators who are designing these checklists.

What does it mean to teach? Webster's dictionary defines teaching as, to cause or help (a person) to learn how to do something by giving lessons, showing how it is done, etc. Teaching is not necessarily about instructing our fellow healthcare providers about the sophisticated immune system pathophysiology involved in anorexia and cachexia seen in advanced cancer or the intricate balance of opioid receptors modulating pain. We can teach about the importance of alleviating the suffering of patients and families by focusing on all aspects of total pain: physical, emotional, spiritual, and social pain as directed by Dr. Cicely Saunders. ¹ We can teach in our conversations with people, teach by example in the way we interact with staff and care for patients and families, the way we act as their advocates and we can also teach in a lecture or other formal settings. We have come so far in our field, but we still have so much to do. We are all teachers.

This is an exciting issue because it has an abundance of information relevant to making us better teachers. There is an article on training programs to improve palliative care team communication skills with the COMFORT communication curriculum for palliative interprofessional teams. ² Another article discusses a model for primary palliative care education for advance practice nurses (APRNs). ³ These types of programs will likely be integral to addressing the impending shortage of palliative medicine providers. Monterosso et al. have identified areas of ambiguity regarding the meaning and delivery of palliative care within the acute care setting. ⁴ This knowledge will give us an opportunity to teach hospital providers about the benefits of involving palliative medicine in the care of their patients. For those JPM readers involved in teaching medical students and residents, there are articles on demonstrating competency in palliative care using observed structured clinical examination (OSCE) and a piece on assessing a resident's ability to assess patients and end-of-life (EOL) views.^5,6 Education is an ongoing process and it is important for us to train the next generation of educators and to know how they are being trained so that they can continue the advancement and expansion of our field. Seow and coauthors report on their development of a tool to survey patient's and caregiver's feedback about EOL experiences. I suspect that we all know how powerful a teaching experience can be when patient's personal stories are included. ⁷ This type of research will certainly improve care and our ability to engage our audiences.

Remember, we are all teachers.