I was recently watching an online interview with one of my heroes, Dr Neil deGrasse Tyson, the famous astrophysicist and director of the Hayden Planetarium in New York. During this interview, the philosophical topic of public science education came up. The interviewer referenced a comment that Dr Tyson is a “knowledge pusher.” Now, anyone who has heard of Dr Tyson can understand why that epithet was applied to him. Dr Tyson’s response was that he is not a knowledge pusher but rather he attempts to inform our population so that we can question the world around us. As a podiatric educator I have tried to adhere to this philosophy as well. However, some have a problem with this type of teaching. Should we teach our trainees to question or adhere to our collective wisdom?

Let me put this question to bed fast. We should absolutely train our underlings to question the status quo. Does this sound obvious to you? If so you’re the open-minded person who is ok with others questioning you. You have the confidence of your own experience and knowledge to stand up to others’ criticism. This is not true for many others in the field of medicine.

After my 17 years of training and clinical practice I’ve met enough people and seen enough training programs to know that there are two primary types. The first is the classic type, the hierarchy. At these locations trainees are indoctrinated into a very specific educational structure in which the less experienced trainees learn from more experienced trainees, and they in turn learn from the attendings. Questioning the attendings is prohibited, and moving outside the hierarchy is not allowed. The most experienced trainees do the most advanced surgical cases while the less experienced do the “scut” work. This is the way medical training was conducted for much of the modern history of medicine.

The other type is a less formal, less structured format in which the hierarchy is more limited and questioning is the norm. Surgical cases may be chosen by what the particular trainees need rather than by experience year. For example, I might take longer to perform a bunionectomy independently than my co-resident and need a larger volume of these cases. Instead of picking based on year, the choice is made by necessity and educational goals.

The other aspect of this type of program is the creation of an environment that allows questioning authority. For some, the first part mentioned above may not be so much of a stretch, but this second part may be a bridge too far. At the residency program I run this is exactly the environment I have worked to create.

For those that have trouble with this idea – and I’m sure there are plenty of you – here’s my reasoning. First, an environment that allows questioning also permits exploration and interest. I want my residents to come to work each day motivated and engaged in what they are doing, and this is one way to establish that motivation.

Second, none of us know the answers to every question or clinical scenario, and creating a situation in which teachers falsely state their omniscience breeds ignorance in their trainees. I want my trainees to be the best-informed physicians, and this is impossible without direct inquiry.

Third, we live in a modern world in which the best evidence increasingly drives care choices. If my trainees do not question, how can they learn to use the tools of the evidence-based world to make decisions? They will have not only ignorance but also the inability to move their own knowledge forward after leaving training.

Finally, a questioning environment allows freedom for creativity. Here’s an example. Let’s say I’m doing a surgery with one of my residents, and the hardware to fixate an osteotomy fails. If I just take over and tell the resident what to do he won’t learn how to get himself out of trouble. Instead, by giving him a little leeway to work through the problem (and only intervene if he gets truly stuck) he will better learn for the future, while improving both competence and confidence. Is that not the purpose of teaching in the first place?

Now, this is by no means an easy process. I can tell you that some of the attendings associated with my residency program don’t like the environment I’ve created. They may appreciate the more traditional authoritarian approach of other programs and may be uncomfortable with trainees that don’t believe everything they say because they are the supposed experts. The same may be true for some of you. I can tell you that it’s often uncomfortable being constantly questioned by those you are teaching. It does take some confidence to hold your own and perhaps even more so to admit when you’re wrong.

If you want to build a more open and questioning teaching environment here are a few suggestions:

If you start here and maintain a respectfully questioning training environment you’ll find a new vibrancy in your educational world. Who knows; you might even learn a thing or two yourself.

*Approved for 16 CME/CECH Credit Hours

PODIATRISTS: This activity has been planned and implemented in accordance with the standards and requirements for approval of providers of continuing education in podiatric medicine through a joint provider agreement between the New York College of Podiatric Medicine and PRESENT e-Learning Systems.

The New York College of Podiatric Medicine (NYCPM) is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine. The NYCPM has approved this activity for a maximum of 16 continuing education contact hours.

PHYSICIANS: Professional Education Services Group (PESG) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Professional Education Services Group (PESG) designates this live educational activity for AMA PRA Category 1 Credits^TM. Physicians should only claim credit commensurate with the extent of their participation in the activity. A maximum of 16 AMA PRA Category 1 Credits^TM will be awarded.

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