They who teach are brave, not incompetent

Rinckside 1998; 9,2: 5-7.

here is an old saying: He who can does; he who can't teaches. I have never understood the mentality behind this statement. Surely someone who can communicate the contents and context of a discipline to somebody else must understand the field well and is certainly not incompetent.

Fifteen years ago I was involved in the organization of one of Europe's first workshops on magnetic resonance in medicine. I was fascinated by one of the participants from the United States. I talked to him during a social gathering one evening and found out that he was a professor of radiology from one of the New England states. He was solely involved in teaching radiology at the college or university in which he worked.

This I found amazing because in Europe, as a rule, being a professor of radiology implies that you work at a hospital or that you are the head of a university department where you spend your time with administrative tasks, taking care of patients, and – sometimes – teaching students or residents. However, teaching usually is not the most important part of a radiology professor’s job. On the contrary, some considered it a sideline or a kind of hobby, like playing football with the children or collecting stamps.

Occasionally, teaching radiology is even deemed a burden – or made a burden – by the university or hospital administration, instead of a challenging and critical task of a professor.

Of course well-performed teaching at a university level is expensive, and bureaucrats do not see the need to pay for it. For example, Norwegian newspapers have uncovered a long-simmering minor scandal recently: Money paid by the government for medical school teaching all over the country was channeled into other parts of the healthcare system by provincial government and university hospital functionaries. Nobody has been punished for it. In the end, the people who suffer are those who need qualified, well trained physicians. As it is, Norway has too few radiologists – or physicians in general, for that matter – to take care of the population. In poor countries this would be understandable, but Norway is not a poor country.

   Professors are essential. The root of the word professor is profiteri, the Latin verb for declaring or teaching publicly. Professors should be pedagogues. However, teaching is rarely properly remunerated, and running the department and examining as many patients as possible in a given time are considered higher priorities because they produce money straightaway.

The rapid development of diagnostic imaging makes it difficult to keep up to date. Radiologists who trained fifteen or twenty years ago, may well have no more knowledge of imaging procedures or clinical management of imaging procedures as a referring physician – in other words, the person who should advise on the best procedure for the benefit of the patient knows as much as the doctor asking for a suggestion. Unless they have attended numerous continuing education courses, both will have rather limited knowledge.

   Five years ago, nearly half of all board-certified radiologists in the United States were older than 47 years. This means that 50% of the US radiologists were not formally trained in the new technologies such as MR imaging, ultrasound and interventional radiology, perhaps even not x-ray CT. How did they keep up with the developments in the field?

Most of them spent a lot of time and money – their own and that of their employers – in continuing medical education. The United States are well known for excellent teachers in continuing education. Europe is trying to catch up, and small scale teaching courses have been established in many countries.

Some national congresses such as the French, Spanish and German increasingly devote program slots to well-prepared continuing education courses. Some of these courses are presented in a manner which was frowned upon in Europe some years ago – not the serious and dull teaching that resembled smelling the dust of previous centuries, but lively, humorous, and pedagogically well conceived presentations where the audience understands the message. These congresses were completely overhauled in the last years, and they compare favorably with continuing education on the other side of the Atlantic.

Still, it is nearly impossible to get an overview on the various radiological, or better imaging, technologies and methods. Decision-makers often have their own ideas and theories about which technology to use. In addition, because radiology is at the crossroads in medicine, physicians from other disciplines have limited, if any, guidelines that dictate which technique to use for a given diagnostic situation. In most cases, they have learned about the techniques from people who have not been trained to give such information. Ultrasound, the most costly diagnostic imaging modality in medicine, is the best example of this expensive deviation in the health system.

The only way doctors can form their opinions and make their decisions is by obtaining good information, and one way of doing so is through continuing education. For this, independent teachers are indispensable. There are numerous dependent teachers – such as company employees who sing the company song or representatives of pressure groups. Doctors need objective, independent opinion. University professors dedicated to teaching radiology or similar teachers in radiology are the best choice.

Challenges of radiology

Teaching radiology is particularly challenging and preparing radiological lessons is extremely time-consuming. There is a lot of truth in a statement by Seneca: "Homines dum docent discent – While they teach humans learn". I learned this at school, but I only started to appreciate the validity of its contents later in life. If you want to (or have to) teach you better know exactly what you are teaching – thus you learn it.

This is best seen in the feedback. Sometimes during or after a lecture teachers may be asked questions for which they don’t have a ready answer. I used to think that I would lose face in such a situation. Today I know that it is better for both parts, the teacher and the pupils, if you say: "I cannot answer this at present, but at the next lecture (or whenever it is convenient) I will explain it to you". This is better than giving a wrong answer, beating around the bush, or talking for five minutes without saying anything. These tactics don’t fool anyone. The people in the auditorium will grasp anyway that you do not answer the question – particularly, because some of them usually know the answer. For a politician or a diplomat avoiding straight answers is part of the job, for you as a professor it is not.

Radiology teachers are needed for two main groups: students of medicine and radiological technicians who require an introduction to general radiology as part of their basic training; and residents and board-certified radiologists who need information updates and introductions to new techniques so that they may continue working as competent radiologists.

In order to facilitate this instruction, I would divide radiologists into four subgroups: those who spend the entire day in clinical routine, those who spend part of the day in the clinic and part in research, those who mainly work as administrators, and those who teach.

An article I recommend is: "Careers for a Lifetime: The Role of Continuing Medical Education" [1]. It is a career for a lifetime to go into radiology and, especially, into teaching radiology, because proficiency requires decades. The teacher must first learn the subject which may easily take ten years. Perfecting lectures takes another decade, and another ten years go into upgrading both knowledge and teaching materials – the times of the radiological professor who could teach his students chest x-rays in the same manner he had done it twenty years ago have long passed. If your knowledge is not up-to-date you are out because your students, residents, or radiological colleagues in continuing education may know more than you. They will vote against you with their feet – by walking out of the auditorium.

An additional question concerning the teaching of radiology is: Can we still have the universal and general radiology teacher?

The answer is yes, but also no.

As I have mentioned in previous columns, the arrival of new technologies and subspecialities in radiology means nobody can expertly practice all of them – at least not with their hands – but some theoreticians can practice them mentally.

Some pedagogically adept people should be able to enjoy the luxury of keeping up to date in all radiological subspecialities – at least from a theoretical perspective. Thus, departments of neuroradiology, pediatric radiology, or interventional radiology ought to accept visiting radiologists to "spy" on what is going on, filter it, and pass it on the theory to their disciples.

Ongoing process

For hands-on continuing education, those radiologists interested in a specific field have to come to the specialist. This approach holds not only for radiologists but for physicians in general.

In 1990, the World Federation for Medical Education distributed a statement on medical education in Europe where you find the following sentences:

"The most important aim of the undergraduate curriculum is to equip the student to be a lifelong self-directed learner, willing and able to make use of postgraduate and continuing medical education. …

"Undergraduate education is only the first phase in a continuum of lifelong learning ... On completion of postgraduate training, all doctors should certainly maintain their professional competence as long as they continue to practice medicine; this will require them to participate in continuing medical education programs [2] …"

There is nothing to add to this.

References

1. Alazraki, Naomi P.: Careers for a Lifetime: The Role of Continuing Medical Education. Radiology 1992; 184: 603-604.
2. Report, 1st Mediterranean Medical Meeting, Crete, 26 September 1989: Statement on Medical Education in Europe. Medical Education 1990; 24: 78-80.

Citation: Rinck PA. They who teach are brave, not incompetent. Rinckside 1998; 9,2: 5-7.

A digest version of this column was published as:
He who teaches is brave, not incompetent.
Diagnostic Imaging Europe. 1998; 14,9: 21-22.