Personal view or opinion piece
Open Access

Did medical curiosity kill the cat?

Till Johannes Bugaj[1]

Institution: 1. Department of General Internal and Psychosomatic Medicine, University of Heidelberg, Med. Hospital
Corresponding Author: Dr Till Johannes Bugaj (till.bugaj@med.uni-heidelberg.de)
Categories: Educational Strategies, Students/Trainees, Teaching and Learning, Continuing Professional Development, Undergraduate/Graduate
Published Date: 06/08/2018

Abstract

Curiosity is the urge to explore, understand, and discover anything new. Curious doctors act as ‘frontier workers’ between the humanities and natural sciences. In their efforts towards trying to "understand" both their patients and their complaints, they function as detectives searching for every seemingly unimportant detail in their constant endeavor of solving the mysterious medical puzzle of illness and providing their ailed patients with adequate help. The curiosity to discover my patients’ character, to learn their hopes and desires, to explore their past and current social environment is a crucial part of the manifold studied foundation of what is termed medical empathy. Therefore, nurturing curiosity during the course of medical training should be highly desirable. That said, it seems all the more regrettable that medical education often suppresses the development of curiosity rather than nurtures it, often overemphasizing verifiable facts rather than stimulating more complex thought and reflection processes. The importance of medical curiosity, previously neglected as a potent effect and success factor in the medical-therapeutic setting, should no longer be misunderstood or denied its role. We, as physicians and lecturers, have the power to ignite our students’ medical curiosity, if we manage to transmit the "spark". This Personal View by a German MD is intended as a passionate plea for more curiosity in medical education.

Keywords: Curiosity; medical education; medical school; teaching medicine; practising medicine; burnout prevention; medical students; medical doctors.

Personal View

In this day and age, the inquisitive mind can hope to satisfy its thrust for information easily and everywhere. The Internet is teeming with forums and online portals promising the avid seeker swarm-response answers. Perusing these leisurely, I recently stumbled across a forum user’s question on if it was possible to become a doctor without being able to stand the sight of blood. In line with common forum custom, many more or less helpful answers were given, one of which particularly attracted my attention. The respondent assures the unknown questioner that their initial feelings of nausea and disgust would soon be overcome by routine and later be replaced by a growing sense of "curiosity" during further medical training. I caught myself reading the answer again and again. Surprisingly, I was not irritated by the statement regarding the initial feelings of nausea and disgust, but stumbled across the respondent’s assumption regarding the supposedly increasing sense of curiosity - and asked myself if medical curiosity really does grow during the course of our academic years?

From my very first day of residency in a German university hospital, teaching and working in direct contact with medical students from the beginning to the end of their medical studies, the so-called "practical year", has accompanied me on a daily basis. I have even gone so far as to devote my scientific work to the improvement of medical education and the assessment of medical students’ psychosocial burden. My professional years have, therefore, led to many more or less enlightening findings about this student target group. However, they have not evoked the impression that students generally leave our universities brimming with curiosity.

Curiosity is commonly used to describe the urge to examine surroundings, to explore, understand, and discover anything new. In the following, curiosity is always understood epistemically, that is, as aiming to provide organisms with information and new knowledge instead of, for example, as aiming to satisfy a desire for sensation (Berlyne, 1960). It is both a trait in which humans differ, genetically anchored and modified by the environment, and a current state (Naylor, 1981). Hence, curious doctors act as ‘frontier workers’ between the humanities and natural sciences. In their efforts towards trying to "understand" both their patients and their complaints, they function as detectives searching for every seemingly unimportant detail in their constant endeavor of solving the mysterious medical puzzle of illness and providing their ailed patients with adequate help and treatment plans. For this purpose, the curious doctor is repeatedly required to leave the well-trodden paths of classical linear thinking and must instead hope, in a mosaic-like manner, to collect as much information as possible formulating and rejecting numerous suspected diagnoses and hypotheses in the dynamic process known as "clinical reasoning". Faith T. Fitzgerald suggested, in a remarkable article from 1999, that it may well be curiosity itself that turns initially unfamiliar patients into people “we can empathize with” (Fitzgerald, 1999). The curiosity to discover my patients’ character, to learn their hopes and desires, to explore their past and current social environment is a crucial part of the manifold studied foundation of what is termed medical empathy (Neumann et al., 2009). Ample evidence suggests that curiosity generates greater emotional involvement and, thus, potentially greater therapeutic efficiency (Derksen, Bensing and Lagro-Janssen, 2013). In short, curiosity seems to be a key, if not the crucial, prerequisite for professional medical practice. Therefore, nurturing curiosity during the course of medical training should be highly desirable - one could even go so far as to claim that it may symbolize medical students’ maturation or the process of gradual ripening towards, ultimately, “physician maturity".

That said, it seems all the more regrettable that, as Fitzgerald commented, medical education often “suppresses” the development of curiosity rather than nurtures it, often overemphasizing verifiable facts rather than stimulating more complex thought and reflection processes (Fitzgerald, 1999). My personal experiences in medical teaching are sadly in line with these observations: at the start of medical training students seemingly exude the curiosity quint essential for their journey to becoming excellent clinicians or scientists. However, it seems to go astray or is simply lost during the course of their medical studies. Prospective physicians practice history taking with validated checklists to ensure that no relevant question remains unanswered – a practice that, at first sight, should be highly welcomed. Problems arise, however, if any deviation from the pre-structured "history taking kit" is called for - a development that seems, at least partially, systemic as long as our students, burdened by close-knit curricula, demanding study regulations, and hectic hospital work realities, are coerced and conditioned to perform their tasks to the greatest possible efficiency.

The other day, for example, an ambitious final year medical student informed me that a 68-year-old CHD patient he had admitted suffered from "severe malaria" and had indeed "almost died" in the course of a long ICU-treatment 14 years ago. Upon my inquiry where this had happened and by whom the patient had been treated, the student replied that he had stopped his exploration at this point as the patient was “after all in the hospital for elective coronary angiography”. The art of focused case presentation is an important learning goal in final year medical training and, admittedly, malaria had nothing whatsoever to do with the patient’s current symptoms. However, if circumstances allow, patient history taking should necessarily include interest-based inquiries beyond emergency and intensive care settings. I must say that I had difficulty in understanding why the student had not mustered any "fascination" for both the disease, so uncommon in Germany, and the story behind it, hence, ultimately for this patient. Every patient tells a (different) story. Time and setting permitting, listening to these stories attentively, that is, learning about our patient´s (past) health and disease experiences, provides us with invaluable opportunities to extend our medical knowledge and imagination – in short, makes us better doctors.

On another occasion, a young patient with obsessive-compulsive disorder had a large abdominal scar and during physical examination the examiner was able to feel a strange foreign body right under it. As it turned out, this was an internal pulse generator (IPG) placed into the abdomen for the purpose of deep brain stimulation (DBS) - a fact that, despite all rarity, hardly aroused astonishment or evoked curious questions (e.g. about the indications of IPG-implantation or its operating principle) in the final year medical students present at the time. Of course, these are individual case observations and I am luckily able to cite endless examples of inquisitive and curious students. However, what remains is the misgiving that when we are busy designing daily classes for our clinic teaching sessions and auditoriums, we do not always have the encouragement and promotion of student curiosity in mind. On the contrary, young resident physicians, in particular, often feel challenged by their student audiences’ scrutiny and frequently resort to hamstringing behavior in their attempts to prevent prolonged cross-examinations for fear of feeling compromised by having to reveal their own knowledge gaps.

However, for the practicing clinician, curiosity can mark the difference between "autopilot" routine case processing and the invigorating experience of daily exploration and discovery of new challenges and learning opportunities (Schattner, 2015). This is particularly relevant in light of the fact that as many as 20% of medical students already show signs of significant burnout burden by the end of their medical studies (Koehl-Hackert et al., 2012). Accordingly, one could assume that a well-preserved sense of epistemic curiosity may be able to act as a preventative factor against psychosocial burdens, including the burnout syndrome, whereas the loss of curiosity - the curiosity in others - could be understood as a dramatic sign indicating psychosocial burden. There is no scientific evidence so far, but the suggestion that a curiosity-based medical attitude could be an effective antidote to burnout in this occupational group does not seem farfetched (Schattner, 2015). Effective burnout prevention strategies, such as Mindfulness-Based Stress Reduction (MBSR), already commonly use the element of curiosity, even though the elements of mindfulness and curiosity are almost exclusively directed towards the own self (Krasner et al., 2009). However, in professional life, overburdened colleagues often lose their curiosity for others and encounters.

So what can or must be done to counteract the decline of curiosity throughout the course of medical training? How do we promote this important - and, following the reasoning above, perhaps even protective – quint essential physician quality? Well, first of all we need to amend the common proverb - curiosity did not kill the cat. The importance of medical curiosity, previously neglected as a potent effect and success factor in the medical-therapeutic setting, should no longer be misunderstood or denied its role. Furthermore, we should not forget that, despite all necessary innovation on the one hand (e.g. modern day virtual patients, well-equipped skills labs, and state-of-the-art course formats) and the actual encounter and intellectual debate with our real-life patients on the other hand (which I still consider to be our most important learning platform), our students’ curiosity must still be actively promoted and nurtured. If we discover ways and techniques in the future to better ignite our students’ medical curiosity and to transmit the "spark", we will both shape and inspire our students sustainably, which - probably more than any other instructive moment during training – will serve as catalyst and fuel for learning.

In the Internet forum mentioned above, one user soberly provided the advice that the questioner should look for a "different job" if he or she could not see blood. Posed years ago, the question on the suitability for the medical profession has long since become a fossil data track in the World Wide Web, the answers having become just as outdated. Nevertheless, I would have liked to have added that the mentioned curiosity does not simply emerge out of nowhere to replace any abhorrence, but must be actively nurtured and trained, that it could serve a driving force for the most beautiful profession in the world and that a lack of curiosity could lead to occupational and self-abandonment. The anonymous questioner, that much is certain, will not see my belated answer and has perhaps long since decided to enter into or to abstain from a career in medicine.

Take Home Messages

  • The importance of medical curiosity in medical education and training should no longer be misunderstood or denied its role.
  • We, as medical educators, physicians and lecturers, have the power to ignite our students’ medical curiosity.
  • To do this, we need to develop appropriate strategies and test them in teaching practice.

Notes On Contributors

Dr. med. Till Johannes Bugaj is a German medical doctor currently funded by the Physician-Scientist Programme of Heidelberg Faculty of Medicine.

Acknowledgements

I thank Anna Cranz for her assistance in proofreading the manuscript and translating my thoughts into beautiful English words.

I thank apl. Prof. Dr. med. Christoph Nikendei, MME for having been such an invaluable mentor, nurturing my own scientific curiosity over the past years.

Bibliography/References

Berlyne, D. E. (1960) Conflict, arousal, and curiosity. New York: McGraw-Hill. https://doi.org/10.1037/11164-000

Derksen, F., Bensing, J. and Lagro-Janssen, A. (2013) 'Effectiveness of empathy in general practice: a systematic review', Br J Gen Pract, 63(606), pp. e76-84. https://doi.org/10.3399/bjgp13X660814

Fitzgerald, F. T. (1999) 'Curiosity', Ann Intern Med, 130(1), pp. 70-2, https://doi.org/10.7326/0003-4819-130-1-199901050-00015

Koehl-Hackert, N., Schultz, J. H., Nikendei, C., Moltner, A., et al. (2012) '[Burdened into the job -- final-year students' empathy and burnout]', Z Evid Fortbild Qual Gesundhwes, 106(2), pp. 116-24. https://doi.org/10.1016/j.zefq.2012.02.020

Krasner, M. S., Epstein, R. M., Beckman, H., Suchman, A. L., et al. (2009) 'Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians', Jama, 302(12), pp. 1284-93. https://doi.org/10.1001/jama.2009.1384

Naylor, F. D. (1981) 'A State-Trait Curiosity Inventory', Australian Psychologist, 16(2), pp. 172-183. https://doi.org/10.1080/00050068108255893

Neumann, M., Bensing, J., Mercer, S., Ernstmann, N., et al. (2009) 'Analyzing the "nature" and "specific effectiveness" of clinical empathy: a theoretical overview and contribution towards a theory-based research agenda', Patient Educ Couns, 74(3), pp. 339-46. https://doi.org/10.1016/j.pec.2008.11.013

Schattner, A. (2015) 'Curiosity. Are you curious enough to read on?', Journal of the Royal Society of Medicine, 108(5), pp. 160-164. https://doi.org/10.1177/0141076815585057

Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

Ethics approval was not necessary as this is a personal view only.

External Funding

This paper has not had any External Funding

Reviews

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Sateesh Babu Arja - (13/08/2018) Panel Member Icon
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It is very interesting article. The title itself raised the curiosity to read the article. I thoroughly enjoyed reading the paper.I agree with the author that curiosity is gradually declining among the medical students. I am teaching medical students since thirteen years. I can see the clear disappearance of sparkling curiosity on the faces of medical students while they are gradually progressing through the different years of the medical program. The two reasons I see are the medical curriculums and assessments and medical educators. We are too much focused on blueprinting, rubrics, and checklists rather than holistic approach. Lot of medical teachers are not encouraging the students to ask questions and many times it could be also due to large size classes and not having enough time. Medical educators should have guts to accept the knowledge gaps and encourage the discussions in the classrooms. Medical information is vast and it is ok not knowing everything but we should encourage the students to question why and they should be able to search, analyze, appraise and critique the information. This article might be useful to all medical educators.
Trevor Gibbs - (12/08/2018) Panel Member Icon
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A very interesting paper and not too difficult to agree with the author's interesting observations and points. I suppose we all have our "examples" of students who fail to ask the why question, relying on the what simply because they know that this is what will be asked in any assessment of their learning. If we could re-adjust the standard assessments we use to explore the students understanding rather than measure whether or not they know the standard answer I feel that we can start to increase the curiosity of the student. A good paper for all those involved in curriculum planning, if only to make them begin to think about how we take the students out of the standard "comfort zone" of assessment.
Faraz Khurshid - (08/08/2018)
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Dear Dr Bugaj.
Thanks for sharing this personal opinion-this piece of information prompted my own curiosities as a medical teacher to discern the factors that can stimulate our student's curiosities at an earlier level. The main focus of your discussion is the need and significance of the student's as 'Frontier workers' or ‘Inquisitive detective’ to solve many enigmas of clinical practice. You brought some very interesting examples.
As a basic sciences teacher, I am of the opinion that the curiosity can be nurtured at the earlier theoretical phase of medical education. Reviving students' curiosity can effectively shape the cognitive, affective and psychomotor domains of the learning. Now there has been talking about the incorporation of 'Threshold concept' in medical education. These concepts are troublesome but transformative; it changes the way in which the student views the discipline. It brings together different aspects of the subject (Integrative) that previously did not appear related to each other for students. The threshold concept is discursive as the crossing of a threshold will incorporate an enhanced and extended use of language.
Understanding a threshold concept may demand a shift in learner subjectivity and indeed curiosity, which is implied through the transformative and discursive aspects. Identification of threshold concepts and effectively addressing this conceptual gateway by designing inquiry-based spiral curricula can facilitate effective teaching and support learner’s curiosity to an augmented level.
John Cookson - (07/08/2018) Panel Member Icon
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I enjoyed reading this paper and the comments so far. As teachers/enablers of learning we do need to move whenever we can away from the 'what' to the 'why'. We can do that in out examination systems with a bit of encouragement to question setters. So we can say or write; 'why, given what you know about the likely underlying pathophysiology, has this happened to this patient at this time'.
I have had similar experiences to the author; a patient, mid 20s admitted for treatment of cystic fibrosis. The student took an adequate history of the reason for admission but failed to use the opportunity to find out what is was like to live for years with CF. The patients are so much more interesting than the textbooks.
Nils Thiessen - (07/08/2018)
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The most important question a student can ask in class is "why"? This means, however, that he has to admit at this point that he does not understand the context or that the way in which the context had been explained was not understandable. Unfortunately, many lecturers won't allow this question because they are afraid of having to admit a knowledge gap and do not understand that exactly this situation can facilitate deeper learning for the student as well as for the lecturer himself. I experienced so many lecturers in the past making fun of those who dared to ask questions in class and disrespected them. So it comes as no surprise to me that curiosity is dying out among medical students. For this reason I hope to see future lecturers who dare to openly admit their own knowledge gaps, who dare to make it clear to the students during lectures that their doctrine is not a dogma and that a discussion is desired at all times. I thank the author very much for the courage to describe and publish this topic from his personal point of view.
Meghana Sudhir - (07/08/2018) Panel Member Icon
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With 'curiosity' I read the whole article. A very interesting personal view article which raises the alarm on decline in curiosity among medical students during the course of their various years. The students and may be the curriculum also gets too focused and unintentionally forgets the wholistic approach to patient care. It is our responsibility to ignite the spark as well as to further explore. A reflection on why the decline in curiosity as well as studies into this area will definitely come up with the reasons which we need to tackle.

Our assessment system is getting more and more focused on objective questions be it multiple choices or OSCEs. Is this something which makes our students focus just on exact answers rather than reasoning?

This article will be of interest to both health professions students as well as faculty.
P Ravi Shankar - (06/08/2018) Panel Member Icon
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This is an interesting article on the status of curiosity and its decline as one progress through the medical profession. Time is becoming a rare commodity in medicine and especially in countries where medicine is privatized, time is money. The more number of patients a doctor can treat the higher the return. Being in a tight time frame could hamper curiosity.
The same is true of medical school where time is tight. The duration of study may be too short considering the vast amount of material and information to be learned. The ways in which we assess medical students is also not conducive to promote curiosity. Assessment is increasingly done using checklists and rubrics and behavior and knowledge outside the normal and the expected may not be welcome and rewarded. I agree with the author that assessment still concentrates on testing facts and places lesser emphasis on concepts and deeper learning. With modern technology accessing facts and knowledge has become easier and the emphasis should increasingly be on critical appraisal of information. This article will be of interest to all medical educators.