The Reason for the Reason
I was lucky once to meet a great teacher in residency, whom we will call Dr. B. I met her during my rural family medicine training in Small Town, Canada. Here lore preceded her – countless trainees, patients, colleagues, who have crossed her path agree she is a great human being and doctor.
Up till residency, medical training had sometimes seemed too fomulaic, i.e.
Net Learning = (Duration of rotation) x (Actual Interest in the Subject Matter) x (Teacher's Ability to Get Through to Learner), all raised to the negative power of any fear, ignorance, or low confidence inhibiting a learner.
The difference with Dr. B is that she let me clear the hurdles of pride and awkwardness. The kind of pride that lets you assume you know more than do. The kind of awkwardness that prevents you from asking questions once you see the gaps.
I was also interested in what I was doing in residency. Rural medicine encompassed anything and everything, and rural physicians were attentive teachers. Whether inserting a chest
tube, treating a hamstring injury, or managing hypertension, I got to soak up the wisdom these teachers poured forth. Dr. B was really one of a village of teachers who raised me.
Dr. B’s best lessons drifted into the abstract: I learned about social determinants of health from watching her example. Week One she told me to look up the Black Report, a 1980 research document from the United Kingdom that established socioeconomic inequality as a major health determinant. She emphasized occupational history. You learn more the more you ask – about patients’ self-made fortunes, their trades, their hobbies (Model ships! Motorbikes!), which ties directly into their health limitations and treatment choices. There was so much to discover, she taught me, by finding out what patients DO, and seeing past the “Past Medical History”.
I learned how to apply the 5 Whys approach to root cause patients’ problems. Or, as Dr. B called it “There’s always a reason for the reason”. A patient would come into hospital with serious illness, unwilling to stay one day more for further treatment and investigations.
Why?
On morning rounds you learned her husband was even more frail and exhausted.
Why?
They were caring for a beloved young grandchild at home.
Why?
Their daughter was struggling with addictions in another city and could not get child care.
Why?
The whole situation had drained their finances. There we go, the reason(s) for the reason she wanted to leave hospital. Not so illogical anymore.
On discussing her own travels and professional experiences Dr. B marveled at "this little piece of paper I got from a medical school across an ocean" (referring to her medical degree) that had allowed her such wealth of human interaction and clinical learning. Some people aspire to their dream job, and some become what that dream job should be. Dr. B raised the bar in my mind of what a physician and lifelong learner could be.
Dr. B taught me how to stretch my mind, have confidence in my abilities, and meet the patient as a multi-faceted, fellow human being. If I make a positive impact in the world, as a physician or otherwise, she is a reason for the reason.
Dr. Marissa Tsoi is a generalist family physician and lifelong learner in Calgary, Alberta. She is a clinical lecturer at the University of Calgary, and currently enjoys teaching medical students and residents on urgent care shifts.
