Empathy

Teaching Humility at the Bedside

By Damiana Andonova

In 1906, William Osler addressed the University of Minnesota medical students with some moving words.

“In these days of aggressive self-assertion, when the stress of competition is so keen and the desire to make the most of oneself so universal, it may seem a little old-fashioned to preach the necessity of humility, but I insist . . . that a due humility should take the place of honor on your list [of virtues]”

His words couldn’t be more relevant today.

Humility is an underappreciated skill in a time of global budgets, evidenced based approaches, and cost-containment. The bright, well-read, talented medical students who may lack humility are not uncommon. And while they strive to become the competent and confident physicians their future patients yearn for, they must also pay attention to learn their roles at the bedside, to be the sort of physicians their patients deserve.

Balancing the technical aspects of medicine with the more humanistic aspect of honoring and developing patient-physician relationships is of serious importance at the bedside; negotiating one with the other can be difficult.

Teaching this sort of confident humility, or humble confidence requires experience and practice. It is no understatement to say that teaching humility is hard. But, perhaps, teaching it at the bedside might have its advantages.

Jack Coulehan, MD, MPH, proposed four attributes for 21st century physicians should strive for:

1) Unpretentious openness
2) Avoidance of arrogance
3) Honest self-disclosure
4) Modulation of self-interest

How clinical professors can go about teaching them is not so clear.

There are several schools of thought. One school of thought suggests employing panel discussions with patients and physicians, home visits, book discussions, film screenings as well as the use of simulated, standardized, and real patients.

The other school of thought, and perhaps the most controversial, believes humility can be taught through acculturation. They find that perhaps medical school admissions look for signs of practiced humility in applicants, that clinicians in leadership positions select clinical professors based on the qualities of caring and humility, and that clinical professors model these virtues in all aspects of their teaching. It is very different from the current model in practice—find the best test-takers and find the most meritorious professors and hold lectures.

Still, other researchers suggest that medical students must deal themselves the task of “having heart” by taking time to self-evaluate, to think about shortcomings and areas to improve upon, and to remember there is always more to learn. An article that explores this is “The Importance of Stupidity in Scientific Research”. It is a highly recommended read.

Stephan Genuis similarly speaks of revisiting scientific impotence and integrity to recognize that science, like medicine, doesn’t always have the answers. In this century of rapid information turnaround, finding a way to underscore the importance of humility as part of the patient-physician relationship could decrease medical errors and ironically, iatrogenic and nosocomial disease, which Genuis argues, has accounted for “sobering rates of morbidity and mortality”.

The Stanford Medicine 25 approach to bedside manner deals, in part, with all of these ideas. The Stanford 25 session is taught by a seasoned clinician who welcomes questions, explains thoroughly. A resident then takes responsibility and volunteers to repeat the exam stepping out away from their desk and out of their comfort zone. They practice humility and compassion by teaching the exam to a fellow resident. This builds community, trust, and memory. It also has the potential to foster humility and compassion.

As clinical professors, one can do only so much. But perhaps Karin Hunt speaks of five good starting points.

1. Build confidence.
2. Master the art of great questions—“Who did you involve in the diagnosis? What do your fellows think of this diagnosis? Who was more comforted by the diagnosis you or the patient? ”
3. Get students out of their comfort zone—Allow them the opportunity to practice what you taught.
4. Help students improve.
5. Model humility.

Students, in return, can take responsibility to adopt this in their informal curriculum and spend a few minutes to self-evaluate, to think about the limitations and successes of medicine and their role at the patient’s bedside.

We leave you with this final thought:
 

“Oh that I had the heart to spare you grief! / The grace of humility is a precious gift,” writes Jack Coulehan, in his poem “Pantoun on Lines by William Osler”.

Sources:

Coulehan, J. (2009). Pantoun on Lines by William Osler. JAMA, 302(17), 1844. doi:10.1001/jama.2009.1505
 

Coulehan, J. (2010). On humility. Annals of Internal Medicine, 153(3), 200–201. doi:10.7326/0003-4819-153-3-201008030-00011
 

Coulehan, J. (2011). “A Gentle and Humane Temper”: Humility in Medicine. Perspectives in Biology and Medicine, 54(2), 206–216. doi:10.1353/pbm.2011.0017
 

Genuis, S. J. (2006). Diagnosis: contemporary medical hubris; Rx: a tincture of humility. Journal of Evaluation in Clinical Practice, 12(1), 24–30. doi:10.1111/j.1365-2753.2005.00599.x
 

Gunderman, R. B. (2014). A Call for Humility in the Regulation of Medical Education. Journal of the American College of Radiology. doi:10.1016/j.jacr.2014.03.025
 

Hurt, K. (2013, March 19). Can we teach leaders humility? Let’s Grow Leaders. Retrieved from http://letsgrowleaders.com/authenticity-transparency-trust/humility_and_leadership/
 

Li, J. T. C. (1999). Humility and the Practice of Medicine. Mayo Clinic Proceedings, 74(5), 529–530. doi:10.4065/74.5.529
 

Schwartz, M. A. (2008). The importance of stupidity in scientific research. Journal of Cell Science, 121(11), 1771–1771. doi:10.1242/jcs.033340