We just don’t memorize things like we used to.
Oh, don’t get me wrong…being on the teaching side of forming young doctors, we still expect medical students and residents to memorize way too much information. After countless hours and sleepless nights of reciting Winter’s Rule for metabolic acidosis, envisioning different types of glomerulonephritis or articulating the arcane clinical manifestations of amyloidosis, this data is purged from their minds for the never-ending parade of exams. And, once finished, only a percentage of the knowledge remains.
Now, I’m not saying that these facts – the foundational vocabulary of a young physician’s education – are unimportant. In fact, in some ways, a fluency in pathophysiology, pharmacology and anatomy may help demystify the functioning of the body and the effects of disease. But the successful practice of medicine is not rooted in rote memorization transforming a mind into a warehouse of disparate facts. Instead, to practice well is about becoming an ordered thinker. Recognizing cause and effect relationships, discerning the probability of disease and reliability of tests, balancing risks and benefits of intervention and inaction are all dynamic aspects of caring for patients which rely on reason, intuition and judgment. And this isn’t simply science. It is art. It isn’t a book to be memorized. It is an ethic that must be cultivated.
That is why, when I think of the microscopic histology slides, the biochemical Krebs cycle, Gram stain characteristics of countless bacteria, I should rephrase my original premise.
There are plenty of things that we memorize. We just don’t memorize things that matter like we used to.
When I sit with residents and medical students during their monthly internal medicine rotation at our clinic, I see young, bright, accomplished men and women…who are tired. Oh, they are eager to help, willing to work and passionate about making a difference. But after years of reading and rounding, memorizing and testing, missing family holidays and eating Ramen noodles, these future physicians have changed. For most, I see budding maturity, confidence and curiosity. But there is also a touch of anxiety, uncertainty and cynicism. When I ask them why they went into medicine in the first place, they pause and are a bit taken aback. They are being asked to reach deep into a part of themselves that has been neglected in the raw stress and tiresome demands of the practice of medicine.
That is why I want them to memorize things that matter.
But what does that mean?
Students and residents who are short on time and long on responsibility are looking for practical science immediately useful in the patient room. They are busy and efficient. Taking time to reflect on why they chose medicine as a career and considering whether, in their battle weariness, they still find themselves inspired by the same motives may seem the stuff of cross-eyed, touchy-feely, irrelevant professionalism seminars. You can almost hear it, “Is this on the test, Dr. Worner? No. Well, okay then, let me just check out for a while.”
But let me tell you what, in reality, I have found.
Among these students and residents, I have been indescribably heartened by the light in their eyes when they read Robert Frost’s Stopping by Woods on a Snowy Evening and talk about the deeply human need to pause and reflect (to get lost in momentary leisure, as I wrote in my last essay). Or, as they peruse W.B. Yeats’ The Lake Isle of Innisfreeand rediscover the universal need to have, in their mind’s eye, that oasis of peace which refreshes in the midst of daily toil and stress. I have been humbled by the honest confession of fear and anxiety over mistakes made (or mistakes feared) after reading Dr. David Hilfiker’s heart-wrenching essay, Facing Our Mistakes. Heads nod when we discuss that we are called to do things we ought to do, not just the things we need to do as brilliantly articulated in Lord Moulton’s speech, Law and Manners. And minds seem to open when we discuss that reading William Shakespeare, Charles Dickens or Jane Austen can, not only help you get lost in a brilliant tale, but also to better comprehend the deeply human aspects of our patients and ourselves. To understand that the safety of the herd in efficient and egotistical medicine may also mean the death of intentionality is an extraordinary reminder in the young Dr. Sonia Singh’s essay, Morning Report. And to witness Socrates schooling the overconfident, ambitious Alcibiades reassures that confidence chastened by humility is the only honest way to wisdom. Talks about Dr. William Osler, essays about classic literature, excerpts from King Lear and quotes from G.K. Chesterton bring young doctors and old (increasingly, that’s me) back to the place we once were, but somehow forgot: Hopeful people who simply want to help others because we can and we should.
In these decidedly non-medical resources, we find how they rescue medicine from becoming what it shouldn’t be. These writings are at the crux of vocation; they are the things that matter. They remind us that even more important than the HOW of medicine is the WHY.
I ask the students and residents to save these poems, essays, speeches and excerpts so they may return to them on a dark day, a lazy day, or a day long in the future when they are a different person and the piece will have fuller meaning for them. And if they can commit a line, a stanza, an image to memory… who knows, but I am willing to wager that its sensitive use – its delicate placement at the right moment – may make as profound a difference in the life of a struggling patient as a correct remedy can make in the life of a dying one.
A story is told about Winston Churchill’s prodigious memory. Having memorized Hamlet in his childhood school days, Churchill’s memory unnerved the famed Shakespearean actor, Richard Burton. Burton recalled how when playing the tortured Danish prince, he heard from off stage a low and muttering voice from the first row of the audience.
It was Churchill speaking the lines with me, and I could not shake him off. I tried going fast; I tried going slow; we did cuts. Every time there was a cut, an explosion occurred. He knew the play absolutely backward; he knows perhaps a dozen Shakespeare plays intimately.
One might reason that a capacious memory for Hamlet is impressive, but irrelevant. Perhaps just an occasion to show off, nothing more. But then one must also discount the impact of Shakespeare’s inspiring St. Crispin’s Day Speech from Henry V (when an outnumbered, out-equipped British faced daunting odds against the overwhelming French forces at Agincourt) had on Churchill as he rallied a beleaguered, defeatist Britain against the might of the Nazi juggernaut.
As Shakespeare penned:
This story shall the good man teach his son;And Crispin Crispian shall ne’er go by,From this day to the ending of the world,But we in it shall be remember’d;We few, we happy few, we band of brothers;For he to-day that sheds his blood with meShall be my brother; be he ne’er so vile,This day shall gentle his condition:And gentlemen in England now a-bedShall think themselves accursed they were not here,And hold their manhoods cheap whiles any speaksThat fought with us upon Saint Crispin’s day.
And Churchill spoke (May, 1940):
I have nothing to offer but blood, toil, tears and sweat. We have before us an ordeal of the most grievous kind. We have before us many, many long months of struggle and of suffering. You ask, what is our policy? I will say: It is to wage war, by sea, land and air, with all our might and with all the strength that God can give us; to wage war against a monstrous tyranny, never surpassed in the dark and lamentable catalogue of human crime. That is our policy. You ask, what is our aim? I can answer in one word: victory. Victory at all costs, victory in spite of all terror, victory, however long and hard the road may be; for without victory, there is no survival. Let that be realised; no survival for the British Empire, no survival for all that the British Empire has stood for, no survival for the urge and impulse of the ages, that mankind will move forward towards its goal. But I take up my task with buoyancy and hope. I feel sure that our cause will not be suffered to fail among men. At this time I feel entitled to claim the aid of all, and I say, “Come then, let us go forward together with our united strength.”
In learning medicine, we have memorized a lot. But, in some ways, we have forgotten to memorize the things that really matter.
In earnest, let’s begin again.
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