Let's just call it a dream. I'd had students with me for a month's elective, and a series of frustrations had prompted me to take a day off, throw my gear in the back of the Jeep and head north. I reached Canoe Pool by seven — the sun was still behind the wall of spruce to the east — early enough to allow me that calm stretch of river alone. But by the time I had changed flies a dozen times without hooking a fish, the sun had risen high overhead and it was time for lunch.
I settled against a big pine, popped the cork on a German Riesling and opened a bag of chocolate chip cookies. With sun, wine and the music of the river, it wasn't long before I had joined quite different company.
I seemed to be at the hospital, already rushed, late, headed for Conference Room B to meet my students. But when I opened the door, I saw that four very different people were waiting for me.
I recognized Osler immediately. With his handlebar moustache, wool suit and vest, high starched collar and bow tie, he was the stuff of medical legend. The second gentleman I knew as well, but I could scarcely believe he was there, even in a dream.
Osler made the introductions.
“Hypatia of Alexandria,” he said, inclining his head toward the only woman present, “and Galileo of Pisa. I am William Osler. And yes, that is Hippocrates.”
Hippocrates was taller than I had imagined, but he wore a robe, sandals and full beard, just as he is always pictured. Galileo, in a black velvet academic gown, had a left ptosis and the incredibly piercing eyes of an eagle.
But it was Hypatia who transfixed me. With her golden hair piled in thick coils at the crown of her head, dark eyebrows and lashes accenting deep blue eyes, and sharply chiselled nose and chin, she looked like a goddess. She seemed aware of her beauty and yet disdainful of it. Awestruck, I simply stared.
Osler gave a little cough, recalling me to the meeting at hand.
“You're wondering why we're here,” Hypatia began. “We do this every so often; we get together to discuss things, as teachers.”
“The four of us,” offered Galileo in his heavy Italian accent, “consider our contributions to the art and science of teaching to be our most important legacy.”
“Which is why we are all here,” added Osler. “We would all enjoy an accounting.”
I had a gnawing feeling, as if I were about to take an exam I hadn't studied for. “An accounting?” I stammered. “An accounting of what?”
“Of how we have done,” said Hippocrates. He seemed anxious to get going — to make rounds, I supposed. “Shall we go to the bedside?” he said.
We headed down the busy hospital corridors, past staff and residents who hardly glanced at us, as if this parade of immortals were an everyday occurrence. I turned for the elevators, but Osler was already taking the stairs.
“I guess you might say that we four have set in motion a process for teaching,” said Galileo. “Every so often we like to be brought up to date. How's it going?”
Such is the economy of dreams that it took only an instant for me to summarize 20th-century medicine: Flexner, the rise of the university medical centre, the advent of medical research, of medicare, HMOs and managed care, and the sorry decline in teaching. They only nodded and waited.
“And so,” I said, “here we are today. We have students who are reluctant to think, who prefer television to reading, and computers to patients. We let good teachers go. Those who can't teach are forced to do so. No one has time for students or patients anymore.”
“Another paradox for Zeno,” said Hippocrates. “You have all this science and technology, invented to save you time, and still you have no time. But there is a solution to every paradox. We'll just have to think about it.”
“What happens when your leaders object?” asked Galileo.
“They act largely out of self-interest, I would have to say. They talk about economics — but only their own. They issue policy statements, but mainly concerning turf wars. They hold grand meetings to bestow awards on one another. They meet in lavish resorts to draft examinations for their students, believing this to be teaching. No organization, no board, has ever formally objected to the shortened time spent with patients and students. Not one of them has spoken out against managed care's severe compromise of quality. We have no leaders, especially where teaching is concerned.”
“More questions, if you don't mind,” said Galileo. “Have you found that touching patients is curative? Has your science shown that the simple act of physical diagnosis has healing properties?”
“No, I don't think so,” I answered tentatively. “There are some studies in psychoneuroimmunology that ... no ... we haven't answered that question.”
Hypatia smiled and shook her head. “What about ‘touching’ students?” she asked. “I long held the notion that mentoring was central. You know, touching students' hearts, getting involved in their lives, loving them, in an agape sort of way. What about that kind of thing?” Hypatia, folding her arms, turned to me full in the face and smiled. The histories have told that every one of her students fell in love with her. I could see why.
“I suppose ... well, no, I'd have to say that question, too, remains unanswered. There isn't very much mentoring going on these days.”
“What are the best qualities of good teachers?” asked Galileo.
“Can teaching itself be taught?” asked Hypatia.
“Can a born teacher's gifts be recognized and cultivated?” asked Osler.
“Everyone has a list of the best qualities of teachers, I suppose,” I said, “but there is no consensus. And we do believe teachers can be taught to teach, although there is no one consistent approach. I don't think it's been studied in medicine. And, no, Dr. Osler, no one has mapped out a way to recognize the born teacher.”
“How many faculty members in your school are paid solely to teach?” asked Osler.
“To my knowledge, no one.”
“How do you measure the quality of a teacher?”
“We still don't know how to do this, although some people pretend that they do.”
“Do you know what it is exactly that stifles the curiosity of your students?”
“No.”
“Do you have a scientific approach, an inquiry into the nature of teaching? A working philosophy of teaching, I mean?” Hypatia smiled again.
“No, not to my knowledge.”
“How are things going at the bedside?” asked Osler. “Do you take students to the bedside, to the patient?”
“Not very often these days.”
“Then how do you evaluate your young doctors?” replied Osler, a bit incredulous. “If you don't see them in action, and evaluate their skills at the bedside, then how ... ?”
“Our examination board has developed something called,” I advanced tentatively, “the virtual patient.”
“The virtual patient?” they asked in unison.
“It's complicated,” I explained.
“I'm sure it is,” said Hippocrates.
“It seems to me that what is needed is an institute, a centre for teaching,” said Hypatia, “a centre composed of the very best teachers. You could reward the pure teacher appropriately, and these faculty would be granted the time for students once again. Students would have the chance to form meaningful relationships with their mentors. Pure teaching would become acceptable once more. And you might begin to answer some of our questions.”
But now I had some questions of my own.
“How would this be paid for? Endowed chairs are expensive. And won't you stifle the teaching of those who are not invited into your academy? Who will decide who is admitted? How do you know the product of your medical schools will be any different once you have this institute of teaching? We think in terms of outcomes these days.”
“Start small,” said Osler. “At one university to begin with. Choose a university already so inclined.”
“Raise the money somehow,” said Galileo. “Patch it together through grants, aid from your drug companies, however you can — convince your public that medical education benefits everyone. What you need most is not money, but a will to do this.”
“Then show them some results,” said Osler. “Take measurements, observe, record, communicate. The Harvard president Charles Eliot was fond of saying that ‘the first step toward getting an endowment was to deserve one.’”
“Can any doctor, by the way, be worth a seven-figure income?” asked Hippocrates. “It seems to me that you have other hard questions to answer while you quibble about funding. And, while you're at it, test your students with real patients, for heaven's sake!”
“As to your question about stifling teaching,” said Hypatia. “You've told us that only a few select scientists are handsomely rewarded for their research. Has the Nobel Prize stifled research?”
“You ask who will decide who is admitted,” said Hippocrates. “The first few members to choose will be obvious. Then simply let those people have a free hand in further admissions. If there is one characteristic common to all great teachers, it is intellectual honesty. You can trust them not to curry favour or pick their friends.”
Osler leaned toward me. “You asked whether the product of medical schools will be any different after the founding of such an institute. Isn't that a rather profound question deserving of an answer? All the more reason to give it a try, I would think.”
Hypatia paced excitedly.
“Do you see what this holds for you? This centre, this academy, will be a repository for knowledge of teaching. Even if it does not grow beyond the walls of one institution, it will be one place on earth that still holds teaching supreme, that preserves the values of analytical thinking ...”
“…and the art of palpation of the peripheral pulse,” said Hippocrates, “and the succession splash ... ”
“…and percussion of the chest ... ” said Galileo.
“…and the diastolic rumble, the anacrotic notch, the Means- Lehrman scratch,” said Osler. “And talking to patients!”
“Perhaps,” said Hippocrates with a broad smile, “we will become immortal after all.”
And then all at once I was no longer there for them. They were engaged wholly with each other, catching up.
I awoke to the chill of dusk, my back lame from the bark of the pine, the dream still a palpable part of me. I rose to go, turned from the river and headed up the path to the road.
Sometimes at an airport or in a city centre, I think I have seen one of them. I see a handlebar moustache under twinkling eyes, or a bearded man taking long, confident strides. A pensive man with piercing eyes stares at me, waiting for my answer, and on occasion a woman of incalculable beauty and intelligence smiles at me and nods. They are still with us, these four. I know it. Together with the multitude they have taught.
Footnotes
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Competing interests: None declared.