Editorial: The Learning Curve

Lisa Rosenbaum, MS IV, BA

Disclosures

On November 26, 2004, Teri Reynolds,[1] launched "The Learning Curve," a new eSection for medical students and residents. And today I am pleased to announce that The Learning Curve has officially arrived, with a talented and diverse Editorial and International Advisory Board.[2] Today also marks our first series of publications that will appear throughout the week, beginning with an article by Farmer and Gupta[3] entitled "International Electives: Maximizing the Opportunity to Learn and Contribute." Although we are sadly losing Dr. Reynolds, our gifted editor-in-chief, she has left in her wake this budding eSection that I am honored to have the opportunity to maintain and grow.

Writing and medicine have always seemed to me the most complementary of unions -- each approach somehow pushing the other to levels that neither can achieve alone. Although I believe now that medicine can be explored through all different types of writing, my first exposure to this pairing was through stories. My grandfather, who is a physician, a writer, and my hero, has been telling me stories about medicine and his patients since I was old enough to hold my head up while bouncing along on his shoulders. His gravelly voice would march through endless characters, each one proffering a unique wisdom, an unparalleled quirk. Yet as a group, despite being so distinct in my grandfather's telling, their individualities blended to give me my first glimpse into the intractable impulses that sprung, when all was said and done, from being human. I would slide my cheek on his waxy, bald, freckled head, my fingers ruffling the small remaining thatch of white hair that my grandmother, to this day, maintains in sleek symmetry.

And despite the fact that my grandfather turns 90 this month -- his body rigid with Parkinson's disease, his voice tremulous, his hands far too unsteady to write -- his stories are more numerous then ever before. He dictates them and mails them to me. He is, in fact, writing the book of which he fantasizes that we will publish together, and he has high hopes that this will make me famous (that is, sufficiently famous at least to leave medicine just for a little while and make him a great-grandfather). After the first 2 years of medical school, I wasn't sure that I would have anything to contribute to his rich tales, but now that I have completed my third year and clinical clerkships, I am about to burst with things to say.

The last time when I was home visiting my family in Portland, Oregon, I took my grandpa to lunch with some of my cousins, as well as my father and my uncles who are also doctors. We ate burritos. My grandpa, ever eager to experience all that has become available to my generation, from technology to ethnic foods, finds burritos to be quite clever. This time he ate about half his burrito and then stood up to leave. "Thanks for lunch, guys," he said, angling his walker to make a beeline for the door. I knew that he did not want help. And so I watched. I watched his solid figure make its way across the restaurant, the classic shuffling gait that picks up speed in that pathognomonic inertial gust. I watched as he bent slightly forward, his body laden with tone, still sheltered by the blue cardigan that buttons midway up his belly, looser now than it was when I was 3. I watched, struck by the determination and grace that united his staccato movements in a jarringly beautiful triumph of man over disease. And I watched, finally standing, the whole affair in agonizing slow motion as his toe caught the mat in front of the door, and he made 3 hasty attempts to dislodge his foot, his walker reduced to nothing but a piece of metal to interfere with his imminent descent.

I arrived by his side the second when his head hit the floor. And despite nearly 3 years of medical school, I could not have acted less doctorly. Instantly forgetting all that I knew about ABCs and c-spine immobilization, I went straight for his head, cradling it in my lap, my cheek instantly returning to that miraculously untouched patch of bald head -- still waxy, still smelling like my grandma's perfume and a little bit of applesauce. And then I sat with him on that cold restaurant-chain floor and sobbed. There was a flurry of activity around us -- my father, my uncles, the restaurant manager, everyone rushing to his side. My grandpa lay, momentarily stunned. "You ok dad?" one of my uncles asked. "Fine," he said. Luckily my grandfather is as resilient as he is stubborn. With a little help he was on his feet, and before I could rise and assist him, he was on his way once again.

I stood next to him outside as we waited for my father to drive the car around. I pleaded with him to be less stubborn, to let us help him while he walked. He ignored me. I kept talking, sniffling a bit. Finally, he turned to look at me. His face was bloody from a laceration across his cheek, and his forehead was marred by a rising welt. His blue eyes twinkled with love, with the excitement of sharing. "Lise," he said, "I have an idea." I said nothing. "You know those walkers have a design flaw. We should remodel them -- they are treacherous." He added, "50% of hip fractures among the elderly are fatal. Imagine how many lives we could save if we created a better walker." I listened to his engineering plans, listened as he included mention of the many friends that he had made in his assisted-living home -- friends who now figured prominently in his stories, and who would each benefit uniquely from the redesigned walker. I took his arm, then, and he let me help him into the car.

For my grandfather, being a physician involves far more than a fund of knowledge; it is, quite simply, a way of life. The tools of learning bestowed by medicine, of turning the world inside out and trying to make it a little better, of staring at a patient while gaining insights into life's mysterious psychodynamics, are lifelong gifts. He has found a way to keep his learning curve eternal -- through writing, through telling stories, and by constantly using the knowledge that he has gathered to reevaluate the world around him. I think, however, that for those of us in training, in which each day brings infinite new things to know, and of course, infinite amounts to forget from the day before, it can be difficult to remember that there is far more to becoming a doctor than amassing a sufficient knowledge base. And although our survival as trainees is predicated upon knowing enough, we are also uniquely poised to apply what we have learned thus far to the exploration of the world of medicine, from the lovely idiosyncrasies of our patients, to molecular pathogenesis, to the economic challenges faced by our healthcare system.

As Teri Reynolds so eloquently stated in her editorial launch of The Learning Curve, "There is a clarity of vision that comes with the shock of the new, and it provides an unparalleled occasion for questioning assumptions. The Learning Curve -- the new section of MedGenMed for students and residents worldwide -- is dedicated to this perspective.[1]"

I am thrilled that this forum has arrived. Like everything in life, in medicine, it will be whatever we, as readers, as editors, and as contributors, decide to make of it. My hope, though, is that the perspectives, discoveries, ideas, and stories articulated in this section will kindle among us the excitement and creativity inherent in medicine so that all of our learning curves have the potential to remain steep.

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