By MARTIN SAMUELS, MD (6)
Everything we know about Socrates comes from his student, Plato, as Socrates left no written record. According to Plato, Socrates practiced a type of pedagogy (or what is now called andragogy as per the adult learning theory of Malcolm Knowles). The Socratic practice involved engaging in a dialogue or debate between the teacher and student which iteratively excludes unlikely concepts leaving the likely correct answer. When I was at Williams College I was regaled with a quotation from James A. Garfield, later a US President, but then a college student, about Mark Hopkins, the eminent teacher and president of the College, who wrote: “The ideal college is Mark Hopkins on one end of a log and a student on the other and you may have all the buildings, apparatus, and libraries without him.” The tradition has continued in the Colleges of the Universities of Cambridge and Oxford and in other eminent institutions around the world. The practice eschews the alleged value of buildings, equipment, computer programs and social media.
Sadly, in the modern education of young doctors the practice has been bastardized to something called “pimping,” by which is meant quizzing the student to try to guess what the teacher is thinking, and even worse, to produce a “so-called differential diagnosis” in hopes that among a long list of incorrect ideas will be hidden the right idea. It is now seen as advantageous to “expand” the differential diagnosis, to improve the likelihood of including the right answer. Secretly, the modern “teachers” are often actually using the student to give them some idea of what the answer might be mainly because they don’t have the expertise to do this themselves. Thus, guessing what they are thinking is futile as they are not thinking anything coherent.
This practice has multiple untoward effects. One, the unnaturally long list of possibilities leads to excessive testing (eg images, genetic tests, electrophysiological studies) which are expensive, time consuming, sometimes unpleasant for the patient (eg EMG, lumbar puncture) and occasionally even fatal as interventions, such as surgeries, are pursued for “incidentalomas.”
It should be remembered that the “normal” range for any test (eg serum sodium, prostate specific antigen, etc) is determined by performing the test on a large number of apparently normal people, creating a bell shaped curve and determining the mean and two standard deviations. Those values greater than two standard deviations from the mean are deemed “abnormal.” Thus, if a hundred tests are performed, we can expect that 5% will fall in the abnormal range, about half too low and about half too high, leading to an asterisk in the electronic medical record. Second, this pimping process can and has led to anxiety in the student. Some students are fine with “expanding the differential diagnosis” to include unlikely or even absurd ideas by using the internet or reciting the index of the textbook of medicine or neurology. However, a significant number of students find this experience intensely unpleasant leading them to skip conferences or hiding behind a black screen on Zoom. This chronic unpleasantness can and does sometimes, lead to depression, feelings of inadequacy which contribute to the pandemic of “burnout” in young people in many fields including medicine. The outcome is the opposite of the Socratic method, which should be a dialogue, with equal respect, between student and teacher.
According to the work of the late Anders Ericsson, true gourmet expertise requires about 10,000 hours of focused practice with immediate feedback. In order to be a better tennis player, one must play with someone more expert than oneself with feedback in real time from the more expert person. This is intensely true in medicine. Hearing from people at one’s own level of professional maturity and expertise may make one feel better as the ideas will not seem alien, but this practice does not lead to expertise. Such people believe that the definition of an entity is defined by committees (guidelines) rather than the biology itself. People trained in this manner may be adequate but not creative and truly expert. A large experience does not by itself lead to expertise. The experience needs to be mindful with input from a more expert teacher. I learned to play clarinet as a child. My teacher would give me exercises and pieces to practice and during the lesson, I was corrected regarding my embouchure, fingering and phrasing. This is the essence of pedagogy (teaching of children). Knowles has argued that learning for adults requires a different method, androgogy (literally meaning teaching of men, but meaning in the modern context, teaching of adults). He argues that adult learning needs to be goal directed and self-propelled. But this is not true. I took up piano in my mid 40’s and my teacher, a very skilled pianist and opera coach in her own right, would correct me in real time just like my clarinet teacher did four decades earlier. For example, she might correct my fingering and would tell me something to this effect: “I know it seems more comfortable to use your thumb to strike this C, but, believe me, when the music becomes more challenging you will see that using your index finger works better. I don’t want you to get into a habit that will be hard to break as you become more expert.”
Of course, there are some “natural” talents that accelerate the acquisition of expertise, but for the vast majority of us, what is required is persistence, patience, mindful practice and correction in real time by a more expert teacher. Socrates and Plato would be turning over in their graves to see how the Socratic method has been misunderstood.
Martin A. Samuels, MD is Professor of Neurology, Harvard Medical School and Founding Chair Emeritus of the Department of Neurology.