Show your work – what my algebra teacher taught me


Category : Medical Rants

The most valuable lesson about teaching that I ever learned occurred in high school. I took my first algebra test. The questions were easy, and I wrote down the answers. All my answers were correct, but I got a B. After each answer, she wrote “show your work”. She explained that while algebra questions start out easy, they become more complex over time. Only through careful understanding of ones thought process could we make progress through the more difficult concepts. We had to have a very solid foundation on which to build our algebra house.

In my journey as a clinician educator, implicitly I understood that lesson. The thought process of medicine always intrigued me. At the Medical College of Virginia where I went to medical school and internal medicine residency, we had some wonderful clinical education role models who took us through the thought process. As I have developed my personal attending style, these role models had a great influence.

Our research on ward attending rounds revealed explicitly what was instinctive. Learners are more interested in how we approach a diagnostic or therapeutic decision than they are in a list of facts. This research helped me understand the difference between true micro-managers and excellent managers.

Micro-managers tell us what to do, but do not explain why. Managers have us discover what to do through an explication of the reasons. Here is my classic example:

Micro-managers look at your IV fluid orders, and either tell you to change the amount of potassium in the fluids, or even worse write the order themselves.

Managers ask you to state the goal of giving potassium. They then teach you how fast you can give potassium. They discuss the patient’s potassium deficit and then help you work through the needed replacement.

The patient gets the same dose of potassium in each case, but in the first case the learner is aggravated and the second the learner has enlightenment.

And it all comes down to showing your work. A belated thank you to my teacher from over 50 years ago (I wish I could remember her name).

Comments (2)

You may not have intended for the following application of what you write, Bob, but your points are also very relevant to some of the process work that is related to the various “movements” in health care (Meaningful Use, PCMH, P4P, ACO, etc.). Much of what we’re now delegating to the staff consists of “click this box,” “record the BMI,” “perform this screen,” without explaining why we’re doing it and how it will help the patient. (Sometimes, unfortunately, there is no such explanation because there is no good reason why we’re doing it and/or it does not help the patient).

I think many physicians who are also going through the motions with these tasks under the “guidance” of compliance officers and quality improvement officers would also benefit from knowing the rationale behind the tasks, rather than simply being told what to do because they have to do it for CMS, NCQA, etc. (The task masters might also benefit from having to explain – and justify – the “whys”)

well said Yul!

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