How can we teach doctors what they don't know?

An interview with Dr. Marc Wein about a unique program for internal medicine residents training at Mass General Hospital

A doctor’s medical knowledge is considered one of our most important traits.

The exams that allow us to graduate medical school, complete residency, obtain a medical license, and maintain board certification are largely based on knowledge of specific facts about how the body works, how it gets sick, and how we can prevent and treat illness and death. Within the profession, we clearly believe medical knowledge is a priority, having medical students spend most of their time in the classroom and lab for two years before spending significant amounts of time with patients in the office or hospital.

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Being knowledgeable, however, is necessary but not sufficient—it’s our application of knowledge that defines the expertise that patients want from us and that we owe to anyone who places their life in our hands. (There are of course many other important qualities in a physician, which we explore in Chapter 9 of Random Acts of Medicine.)

A critical part of that expertise is learning what to do with the deficits in our knowledge. While it seems particularly important today when the knowledge base about the human body is exponentially larger than it was in, say, the mid 20th century before the discovery of DNA, this has always been an essential trait of a good doctor. The Socratic lesson that there is wisdom in “knowing that you don’t know” imposes a degree of humility on physicians, which might seem in opposition to the frequent pressure on us to project confidence.

It takes both effort and experience to effectively balance that humility and confidence in our own knowledge. This means it’s important to train our resident doctors in managing what they don’t know—in addition to the more obvious training in using what they do know—when it comes to taking care of patients.

One way to train medical residents in the unknown

At Mass General Hospital where we practice, the internal medicine residency’s Pathways program takes a unique approach to training physicians in what they don’t know over the course of a two-week training rotation.

I (Chris) sat down with Pathways co-director and endocrinologist, Dr. Marc Wein to learn more about the program (Marc was also one of Bapu’s co-residents, back in the day). I started off my asking him about the origins of the program. (Our interview has been edited for brevity and clarity).

Marc Wein, MD, PhD is an endocrinologist, researcher, and co-director of the Pathways program for the MGH internal medicine residency.

Marc Wein: Around 2016, there were two excited physician-scientist residents, Lauren Zeitels and Victor Fedorov, who felt a little bit frustrated by the fact that they had these really busy lists of patients that they were taking care of in the hospital. They felt there were missed opportunities to learn from their patients who had unexplained things going on, and they wanted to spend more time than they had available to think about those unexplained things.

There were aspects of their patient cases that didn’t make sense, like unusual presentations of common diseases or funny presentations of mystery illnesses. They just really wanted to spend a stretch of time in these proverbial “deep dives” to be able to think about one patient instead of taking care of dozens of patients on a busy inpatient service. They wanted to read as much as they could, talk to experts in the area, and even collect additional samples from the patient to bring to the lab for research.

Chris Worsham: So the idea is if I’m a busy resident that’s responsible for a bunch of patients, we have to do what we can for them in the hospital, get them feeling better and on the right track, and then get them out of the hospital. If there’s something where we don’t really know what’s going on but it’s not a pressing issue, we often just sort of shrug our shoulders and say “it’d be nice to know, but we just can’t deal with this right now, and we’ve got to move on to the next patient.” So with Pathways, the idea is, well, what if you did have the time to actually explore those things that regular patient care just simply does not permit you to do in this day and age?

MW: A big component of this is “how do you maintain your joy in work as a resident?” I think that for many of our residents in the physician-scientist track [who plan on research careers], a lot of that joy comes from discovery and thinking of unknowns in biology and how that applies to medicine. So initially, there was a small group of residents who really wanted to do this, but is has since become a two-week rotation that all residents—physician-scientists or not—all do as part of their training.

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CW: So what do the two weeks look like? Where do they find patients to learn more about?

MW: We have a chief resident who is dedicated to Pathways, and they’re responsible for having a bunch of cases at the beginning of the block. Referrals come in from the other residents working on the hospital floors or ICU. Then we take a look at the referrals to find ones that will be a good patient for Pathways, since often a patient with, for example, multi-system organ failure who’s really sick in the ICU isn’t an ideal case because there’s just too much going on.

Here’s a good case. Recently we had a patient who had an inflammatory disorder which caused him to lose 70 pounds over about a year. The question of “why do you stop eating when you get sick?” is a really interesting question. It gets at things like the body’s control of appetite, or whether there is an evolutionary advantage to not eating when you’re sick, or how nutritional intake impacts your ability to heal or fight infections. There are a lot of great questions here about something we see fairly frequently, yet doctors don’t have the chance to deeply investigate and learn about during normal hospital care. Other good questions have been “why does one patient develop delirium [temporary confusion and hallucination] when they’re sick while another similar patient does not?” Residents can look into what is known about what causes delirium. What are the neural pathways? Why are older people more susceptible? All kinds of big questions come up. And so the first part is case selection.

CW: When I was a chief resident, we would always have the temptation to find these really rare or bizarre cases to use for teaching. And of course those are interesting—that’s why we see them on TV—and they have a role in educating residents. But actually spending time looking into understanding on a deeper level things we think we know the answer to, but really don’t—like what is the actual underlying reason why patients lose their appetite or develop delirium—can offer a lot more teaching as residents begin to develop their expertise. [N.b.: This is a guiding principle over at the Curious Clinicians podcast and newsletter].

MW: Every year we have a new chief resident who comes in, and the first thing we tell them is “this is not an episode of House.” We’re not here to figure out some really clever diagnosis that all the specialists have missed. The goal is to really think about why things are happening the way there are.

Another example is a patient who has had a heart transplant, which means that they don’t have any nerves connecting their brain to their transplanted heart. We might ask: How does that affect their body’s physiology? At the beginning, the team of residents will meet the patient, and might even collect some research samples if the patient is interested. They’ll spend the first day or two refining their questions—and we try to emphasize that the questions need to be simple. Next, they’ll start meeting with experts in the area, and in the age of Zoom, these could be people anywhere around the world. They’ll also meet with one or two of the “core scientists” who are part of the Pathways faculty, but we deliberately choose someone who does not have expertise in the area to help them think about how to answer the questions as a non-expert.

Source: MGH Internal Medicine Pathways

Over the course of their block, they put together an educational conference for everyone that doesn’t focus on the patient’s clinical care, but reviews what is known and what is not known about some aspect of that patient’s condition. They also then propose some experiments that could be done to answer those questions. There have even been a couple of examples of residents taking these research questions, inspired by their Pathways block, back into the lab. [Examples here, here, and here].

CW: That’s fascinating. Are patients generally enthusiastic about this? I could imagine someone being a bit wary and not wanting to feel like they’re being experimented upon.

MW: The way we pose it to patients is “We have a group of trainees who want to study aspects of your illness right now and see if we can come to a greater understanding—most likely, we won’t, but there’s a chance that we will. Do we have your permission to do that?” So expectations are low. But there have been a couple of instances where the teams have developed strong relationships with the patients, to the point where they will even attend the presentation that the residents put on. One patient even presented his own case for the first five minutes of the conference, which was tremendously moving, and the team kept going back and forth to him afterwards.

CW: That’s so cool. I think what interests me the most is that this gets at what you’d call metacognition—thinking about the way we think about patient care. I imagine a big part of this is to give residents a way of thinking about the things they don’t know that will last them beyond this two weeks and hopefully for their entire career. What’s your impression of how the residents see their job or see medicine differently coming out the other end of the block compared to going in?

MW: I think when we’re successful, it has a huge impact. The hardest part is for the residents to transition from a busy hospital service where the thinking is “How can we move this patient through?” to a mindset of “How can we slow down?” So for the first few days we often have to tell them to stop worrying about things like the patient’s daily potassium levels and to focus on the questions that we’re really trying to answer. And then the faculty and chief resident will back off for a bit, and check back in, and it is almost always the case where they have a moment where it clicks on what we want them to do. They often come out the other end thinking “we didn’t realize there’s so many directions that we could go thinking about how our patients presented to us and how we might be able to help them.” And every once in a while there’s someone who finds this so compelling that they consider a research career for the first time.

CW: Regardless of the type of research, one thing that is similar at the core is the importance of thinking creatively about research ideas, finding a good source of those ideas, and honing them into actionable research questions. No matter what discipline you’re in, that’s not an innate skill, right? That’s something you need to practice as a researcher, or similarly, as a physician who is looking to improve patient care. You need to learn how to see what’s in front of you, see there’s something different going on here, admit to yourself “I don’t know what this is,” and come up with a plan to figure out what you should do next. That’s a muscle you have to train and build up.

MW: Yes—and figuring out what the right kind of tool to apply to your question is actually what we spend a lot of time on with the groups, because often the investigation they’re proposing is going to be very different depending on the question they’re asking.

CW: I was thinking about an example that came up with my own practice recently. For pulmonologists, getting patients oxygen therapy at home can be quite difficult, and most of the time we shrug it off as a headache as we deal with insurance and oxygen supply companies. But to look into the question of why is this process so difficult ended up being a fascinating examination of how the health care system pays for these services and the financial incentives that are created. So I imagine there are opportunities beyond understanding what’s happening on the level of the organ, the cell, or genetics.

MW: There are all kinds of huge questions. We had one case of a patient with severe anorexia, and initially we were interested in some of the issues surrounding electrolyte imbalances that can come up. But the team really wanted to go into issues of access to care, and the question they ultimately focused on was “Why is it so hard to get a psychiatric hospital bed for patients with eating disorders?”

CW: I tend to think of the health care system as an organism in and of itself—so to me, this is a question of physiology just as if they had they looked into the body’s handling of electrolytes. The approach is the same, whether you look at it from the 30,000-foot view, under an electron microscope, and everything in between.

MW: I remember when Bapu and I were residents together at Mass General, and he would ask questions on rounds about the policy-level issues that were affecting care. And people would be like “we’re just trying to finish rounds here.” But it’s exactly the same kind of thing—there are so many questions, and you’ve got to be able to stop and think them through. And if you want to do that, you need to be really nimble, you need to be able to pick the right questions and find the right tools to answer them.

CW: So in closing, from your standpoint as an educator, what does this program mean to you? Does it scratch any itches you’ve had when it comes to teaching?

MW: One of the goals of the program when it first started was to have it generate research. But it turns out, it’s not always a great research program, because most of the time, we find something interesting and generate questions that for many reasons we still can’t answer. But, over the years with major input from dedicated colleagues including Dr. Mark Fishman, it has turned out to be this incredibly powerful educational tool for teaching residents ways to approach what they don’t know.

What’s exciting for me is that it’s teaching people how to think and exposing smart trainees who came into medicine for good reasons to new ways of thinking. It’s helping them find new sources of joy in their work and giving them tools to be able to answer questions that might come up in their practice. To me, that is the best thing that an educator could possibly do—just having a little bit of ability to do that is very rewarding.

The two residents who started this program, Lauren Zeitels and Victor Fedorov, both died tragically in an avalanche. They were really passionate about this and instrumental in making the Pathways program happen, and Lauren’s parents continue to attend some of the conferences. So it also takes on this additional deep meaning because of that tragic accident, and in many ways we continue to do this in honor of Victor and Lauren.

(Donations in their memory can be made to the MGH Department of Medicine Pathways fund.)