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An Experience in Learning

1985; Elsevier BV; Volume: 60; Issue: 3 Linguagem: Inglês

10.1016/s0025-6196(12)60216-x

1942-5546

Raymond D. Pruitt,

Innovations in Medical Education

Reams have been written on teaching ability and more will be. There is much vulgar enthusiasm and too little recognition of the deeper meaning of the remark that the verb to teach is not a transitive verb. Why not assume that a teacher leads mainly by his example and that like pathologists we can more readily recognize the result than define the process? I do not ignore the more tangible evidence of ability in writing and speaking clearly and vigorously: in fact I wish we would triple the emphasis currently laid upon the capacity of our recruits to read, write and speak the English language.1Gregg A: Recruitment in medicine. Mayo Foundation lecture delivered on Dec. 14, 1944, in Rochester, Minnesota, and printed for private distributionGoogle Scholar—Alan Gregg, M.D.1Gregg A: Recruitment in medicine. Mayo Foundation lecture delivered on Dec. 14, 1944, in Rochester, Minnesota, and printed for private distributionGoogle ScholarDirector for the Medical Sciences The Rockefeller Foundation Reams have been written on teaching ability and more will be. There is much vulgar enthusiasm and too little recognition of the deeper meaning of the remark that the verb to teach is not a transitive verb. Why not assume that a teacher leads mainly by his example and that like pathologists we can more readily recognize the result than define the process? I do not ignore the more tangible evidence of ability in writing and speaking clearly and vigorously: in fact I wish we would triple the emphasis currently laid upon the capacity of our recruits to read, write and speak the English language.1Gregg A: Recruitment in medicine. Mayo Foundation lecture delivered on Dec. 14, 1944, in Rochester, Minnesota, and printed for private distributionGoogle Scholar —Alan Gregg, M.D.1Gregg A: Recruitment in medicine. Mayo Foundation lecture delivered on Dec. 14, 1944, in Rochester, Minnesota, and printed for private distributionGoogle Scholar Director for the Medical Sciences The Rockefeller Foundation Just a year before this commencement date, I received a letter from Dean John T. Shepherd conveying to me, on behalf of the faculty and students of Mayo Medical School, an invitation to be your speaker today. With pleasure and with promptness that may have disclosed a certain eagerness on my part, I accepted that invitation. Shortly thereafter, I began to ask myself what I could possibly say to this audience that I had not said before. It was a question that I readily postponed answering. In mid-February, Dean Franklyn G. Knox, in an equally gracious letter, reviewed plans for the commencement exercises and divested me of excuses for further delay regarding the mission of my remarks. He said, “I want you to know that the students are most enthusiastic to learn more about the philosophical roots of our medical school and the individual who shaped that philosophy.” Thus, I was asked to talk about Mayo Medical School and to talk about myself! My eagerness to do the former was exceeded only by my enthusiasm for doing the latter. Being properly reared, I have always tried to obscure self-revelation, but with so authoritative an invitation, I shall acquiesce. Forgive me if I overstep the bounds of my mandate. In 1959, the faculty of Baylor University College of Medicine was a blending of the senior guard who had migrated in 1943 from Dallas to the Texas Medical Center in Houston and a group of younger members who had arrived after the translocation, intent on being the molders of a new and different kind of college of medicine. That latter group had been breathing new life into the traditional medical school curriculum for almost a decade before my arrival and were entering a major phase of their revisions at a time coincident with that arrival. The Department of Medicine had its usual ample part of that new curriculum, and I shared with other members of its faculty the stresses entailed in testing the new approaches. I found that some of the novelty intrinsic to these changes bore marks of the familiar, and I had no difficulty recognizing its origin. The chairman of the curriculum committee had preceded me by a few years at Oxford University. At Baylor, he pioneered a philosophy of education that had been nurtured for centuries at that ancient university. It can be summed up in a single short sentence, albeit a tantalizingly cryptic one: “There is much vulgar enthusiasm and too little recognition of the deeper meaning of the remark that the verb to teach is not a transitive verb.”1Gregg A: Recruitment in medicine. Mayo Foundation lecture delivered on Dec. 14, 1944, in Rochester, Minnesota, and printed for private distributionGoogle Scholar Let me try to interpret. “To teach” is not a verb that enforces a specific and predictable consequence. That explanation offered little enlightenment. A simpler interpretation might be found in an analogy with the inevitable frustration that attends efforts to impose one's will on a horse that stubbornly refuses to drink of prescribed waters. Rather, let it be acknowledged that a truly thirsty horse will drink without blandishments, cajoling, or other clever inducements. So let it be with learning. Thus, at the heart of more than a few great universities resides the credo that its students are learners and that to this process those students themselves must contribute the intellectual drive and the emotional commitment essential to scholarly endeavor. The faculty is present to counsel and point the way. With them rests the responsibility for assessing the progress (or lack of it) in the student's maturation as a scholar and for serving as a model of professional maturity which the pupil may aspire to emulate. Professor Arrowsmith, a product of that same ancient Oxford University, defined the rightful purpose of a university and its teaching in all-encompassing terms when he said that it should “convey to the student a care and concern for the future of man, a platonic love of the species, not for what it is, but for what it might be.”2Arrowsmith W The future of teaching.Am Oxonian. Spring 1979; 66: 121-128Google Scholar Now against that inspiring comment of Professor Arrowsmith's, let me set an account of the realities of an experience in learning at Oxford some 50 years ago. That account centers on the tutorial system as I perceived it in preparation for the university's final honours examination in animal physiology. Once each week I would meet with my tutor, a distinguished physician and physiologist, to whom I shall assign the fictitious initials “R.L.” I would come prepared with an essay of some 15 pages covering a topic he had assigned the previous week. As an example, Arthur Grollman's monograph on cardiac output had recently been published.3Grollman A The Cardiac Output of Man in Health and Disease. Charles C Thomas, Publisher, Springfield, Illinois1932Google Scholar My tutor advised that I read it together with articles I found of interest in Grollman's reference lists. After completion of the reading, I was to prepare my essay on the topic of cardiac output and to offer a critical analysis by surveying not only Grollman's work but also related readings supportive of or contradictory to it. I should then conclude my essay with an appraisal of the state of the art of measuring cardiac output and the significance of knowledge so acquired to the broad field of animal physiology. The essay, laboriously prepared during the course of a week, I would take to R.L. for my next tutorial. He would say something to the effect, “Well, Pruitt, what have you worked on this week?” I would state my topic. “Did you find it of interest?” It seemed only elementary courtesy to answer, “Yes, indeed.” Initially, I had supposed he would then say, “Read me your essay.” During the period of 2 years and some 50 essays, however, on only a few occasions did he make such a request. Usually, R.L. would light a cigarette, let it droop from one corner of his mouth, and then through the smoke screen that drifted upward and partially obscured his face, he would engage in a monologue concerning whatever he happened to find of interest at the moment, physiology or otherwise. He had spent a year in the United States, and Americans with their strange ways intrigued him; thus, he would talk about us in a pleasant and kindly fashion. He also liked American “flicks.” As the time for the final honours examinations approached, R.L. did evince an increasing interest in how I was progressing with my preparations. He advised me to secure questions from earlier examinations and to spend several mornings doing trial runs writing an examination, just as if the crucial day were upon me and I were “going for broke.” On six successive Saturdays, I wrote an examination. To my knowledge, none of my colleagues did even one such exercise, a surmise not to their discredit. Scholastic masochism was my forte, not theirs. R.L. did not ask to review any of the papers that I had written. Instead, he sent me this note, beautifully inscribed in his inimitable handwriting. Dear Ray, Cox [the ancient assistant in the laboratory where we did our physiology practicals] puts you on the borderline between one and another of the several classes into which the examinees will be ranked, so topple the balance in the right direction on Thursday and Friday. And don't go opening any books before then. With best wishes, Yours ever, R.L. I read and reread those final lines—“With best wishes, Yours ever, R.L.” From a man as self-contained and undemonstrative as R.L., those words struck home. Thereafter, he gave me one last piece of advice about writing a final honours paper. Even if you think you know enough to fill 20 pages, answer the question in the first sentence. The distinguished examiners who will read your paper are busy men. If, in the first sentence, you can display the good sense of recording the core of your answer, likely as not they will give you complete credit and you can fill the rest of the several pages with trivia, which they may not trouble to read anyway. I thought that advice sounded rather cynical, but it also sounded shrewd, and I was pleased that at last R.L. had suggested something practical. Have I seemed to ridicule this distinguished scholar who was my tutor? Certainly there were times when I left my tutorial filled with frustration to the point of despair. Why didn't he teach me something? Why didn't he listen to my essays and tell me whether they were good or bad? Some tutors did. All he would tell me was that when he took the examinations, he knew physiology, but that was a long time ago. Now I was the one who had to learn physiology and be ready to display my knowledge in clear concise writing that would impress my examiners favorably. He, my tutor, would assign a topic and a book on which to initiate my reading. Everything else was my responsibility: read, get the facts, organize, synthesize, conceptualize. Such was his game plan, but he must have thought that if I did not find that obvious, he would be steadfast in his refusal to stoop to an elementary level of scholarship and explain. In any event, he never did. In the end, an explanation was not necessary. Stubbornly, belligerently, I had played the game of tutor, essay, and final honours examinations even if I was grumpy enough at times to believe that, because of him, I was playing at a disadvantage. Nevertheless, I had to recognize that, like other good coaches, R.L. might have concluded that placing players at what appeared to be a disadvantage sometimes developed better players. Had I been misreading R.L.? That little note had initiated a reshaping of my image of him. Maybe it wasn't R.L. on one side of the battle for learning and me on the other. He did not set the final honours examinations nor did he grade them. We were on the same side in this battle, with both of us out to beat the system. It was a tough examination system that had weathered the centuries. The results could make or break the career of a student and that of his tutor as well. In the final analysis, R.L. and I were colleagues; we were friends, riding out together the storms of insecurity and frustration that beset an experience in self-motivated learning. He actually cared about me and my future. He had done so all along. If I won, he won too! It was just that simple—or maybe it was not just that simple. My reflections of a half century leave me mystified and appalled that I was so slow to see through the game, and slow indeed I was to recognize that, quietly and unobtrusively, my own cherished perceptions of the learning process were being challenged and revised. The ambience of the university and the guiding spirit of my tutor encompassed and permeated my learning. It was an ambience so pervasive and compelling that my mind was impregnated with it and ultimately transformed by it, shattering in the process the cherished certainty of unchallenged parochialisms. Max Beerbohm, the archetypal oxonian, recognized that transformation in himself: “I was a modest good-humored boy,” he once wrote. “It was Oxford that made me insufferable.”4Beerbohm M Cited by Morris J: Oxford's magnificent oddballs.Harpers Magazine. November 1965; : 69-74Google Scholar In at least one significant way, Oxford had also rendered me insufferable. After those years of complaining about the tutorial system and its devotion to the essay as a device in behalf of learning, I became a convert with the ardor of a sinner reformed. I became insufferable in my disdain for those so benighted that they appeared to believe the primary and inalienable responsibility of a graduate school faculty was the forced feeding of facts to its students. They did not understand that the verb to teach is not a transitive verb. The best of learning does not proceed without initial mastery of a core of facts and thereafter acquisition of additional facts as circumstance and career expansion may demand. But does not wisdom dictate that there be an overriding imperative to organize, interpret, and conceptualize those facts into a body of knowledge essential to a lifelong career of learning in a profession that aspires still to retain those age-old insignia of a learned profession? I could easily consume an hour explaining why, if I had concluded that the tutor, weekly essay, and essay-style final examination were superior to other approaches to learning, I did not try to persuade my colleagues on the curriculum committee that we should initiate here at the new Mayo Medical School that same system. The fact of the matter is that I did not have the fortitude. A system so at odds with the curricular approaches of American medical schools was certain ultimately to induce crisis. I did not know who would collapse first: the students, the faculty, or the dean. I believe that we were wise, as the curriculum committee ruled, to begin where the best of American medical education was testing and proving revisions, most of them directed at achieving those same objectives that I had come to revere in the tutor-essay system: direct the student to the facts and then catalyze the organization, interpretation, synthesis, and conceptualization of those facts. If these goals were not to be attained by use of the essay approach, then let them be achieved by other approaches. We adopted the well-tested Western Reserve model of multidisciplinary, integrated organ-system teaching. We urged, to the point of dictating, that didactic presentations occupy no more than a total of 1 hour in a ½-day session. We sought to minimize the hazard of fragmentation by having a single individual responsible for each major segment of the curriculum. On that person rested the responsibility for fostering that much-desired, but rarely achieved, integration. That person was envisioned as a friend of the students—one who would sit with them through didactic presentations, recognize with the students what did and what did not fit into the overall curriculum, and seek revisions when necessary. If fragmentation was beyond redemption, the course would be scuttled. We conceived of each year of the curriculum as a recircling in an ever-expanding spiral. The return to science in year three was envisioned as an opportunity for the student to engage in a “real life” seach for the facts: organize them, interpret them, conceptualize them, synthesize them, and if, on a rare occasion, a lightning bolt of inspiration should strike, hypothesize and create new wisdom! Then the product of all that effort would be clearly and concisely recorded. You students who have been through 4 years of that curriculum can say whether your experiences in Mayo Medical School have borne any resemblance to our high-minded intentions. Perhaps, though, the details of that curriculum were of lesser consequence than were the intentions themselves. We sought to catalyze the processes of learning for students who wanted to learn. Our efforts may have reflected an excess of zeal. It might have been wiser if we had, like my tutor, R.L., described the process and then adopted a role of guidance and veiled but kindly support. The Mayo institutional environment is, in itself, as conducive to learning as was that of Oxford, upon which I lavished such praise. Here as students you have been witness to medical care the excellence of which is rooted in a century of tradition. That excellence is a matchless heritage that endows the present and the future with purpose and preeminence. Medical research and graduate medical education have flourished within the context of that heritage for almost three quarters of a century. This medical school is now assuming and will continue to assume its own singular place within the total institutional environment. Its curriculum may prove to be little more than the ornamental fixtures within the narthex of this cathedral *With acknowledgments to Dr. Frank D. Mann. *With acknowledgments to Dr. Frank D. Mann. of caring, seeking, learning, and loving. You who are now to become members of that school's first decade of graduates have proved your claim to this company of scholars and physicians. To you, I offer my sincere congratulations.