Curiosity and medical education

Abstract

Medical Education 2011:45: 663–668

Context  For doctors, curiosity is fundamental to understanding each patient’s unique experience of illness, building respectful relationships with patients, deepening self-awareness, supporting clinical reasoning, avoiding premature closure and encouraging lifelong learning. Yet, curiosity has received limited attention in medical education and research, and studies from the fields of cognitive psychology and education suggest that common practices in medical education may inadvertently suppress curiosity.

Objectives  This study aimed to identify common barriers to and facilitators of curiosity and related habits of mind in the education of doctors.

Methods  We conducted a theory-driven conceptual exploration and qualitative review of the literature.

Results  Curiosity is related to inquisitiveness, reflection and mindfulness. Instructional practices can suppress curiosity by confusing haste with efficiency, neglecting negative emotions, promoting overconfidence and using teaching approaches that encourage passive learning. Curiosity tends to flourish in educational environments that promote the student’s responsibility for his or her own learning, multiple perspectives and mindful reflection on both the subject and the learning process. Specific educational strategies that can support curiosity in classroom and clinical settings include the mindful pacing of teaching, modelling effective management of emotions, confronting uncertainty and overconfidence, using inquiry-based learning, helping students see familiar situations as novel, simultaneously considering multiple perspectives, and maximising the value of small-group discussions. Instructor attributes that contribute to the development of student curiosity include patience, a habit of inquiry, emotional candour, intellectual humility, transparency and recognition of the benefits to be gained in learning from peers.

Conclusions  Curiosity, inquisitiveness and related habits of mind can be supported in medical education through specific, evidence-based instructional approaches. Medical educators should balance the teaching of facts, techniques and protocols with approaches that help students cultivate and sustain curiosity and wonder in the context-rich, often ambiguous world of clinical medicine.

Introduction

Medical educators recognise the importance of cultivating curiosity to promote the development of perceptive, compassionate and wise health care providers. A recent report from the Association of American Medical Colleges on the sciences in medicine identifies graduating ‘inquisitive’ doctors as a primary goal.¹ Curiosity is central to clinical reasoning and its failure, premature closure, is a common cause of medical error.² In addition, respectful curiosity can help build relationships with patients.³ Doctors need to be curious about their own abilities in order to remain current in rapidly evolving states of medical knowledge and skill.⁴

Despite its significance, curiosity has received limited attention in the medical literature. As Fitzgerald notes,³ closer examination of medical education suggests that many practices may serve to suppress curiosity. This paper will consider curiosity and its derivative attribute, inquisitiveness, from the perspectives of the psychological and educational domains. It will examine ways that medical education can inhibit curiosity and present some alternative instructional strategies with which to nurture it in the development of doctors.

Curiosity, inquisitiveness and learning

Webster’s dictionary defines curiosity as ‘the urge to investigate, to seek after knowledge, to gratify the mind with new information or objects of interest’.⁵ Curiosity is universal in primate behaviour: rats will explore a maze without the impetus of hunger or thirst, and the human infant is transfixed by novelty from its earliest weeks.⁶

Curiosity is a fundamental drive that brings survival benefit to individuals and species alike; it is central to human development and adaptation, and its motivation is intrinsic and does not require external reinforcement.⁷

‘Inquisitive’ is defined as ‘given to examination or investigation, inclined to ask questions, …curious about the affairs of others’.⁵ It is a particularly human trait, reliant on language, and directed toward interpersonal understanding; some hold it as essential to the social contract and the development of empathy.^8,9 In the domain of learning, inquisitiveness is a disciplined curiosity and leads to the development of such habits as reflection, critical thinking and a persistent search for new understanding.¹⁰ Curiosity and inquisitiveness overlap and are sometimes used synonymously, but this discussion will focus primarily on the contextual variables that influence curiosity in all its forms, including the social and affective domains.

Studies in psychology have delineated several types of curiosity that can act independently or in synchrony. Intellectual curiosity is concerned with the acquisition of knowledge, and is ignited by facts that contradict our cognitive mapping of the world. It stirs us to explore and to expand our understanding.¹¹ Social curiosity pertains to the wish to understand the experience of others; affective curiosity concerns the pursuit of pleasure in novelty and stimulation.¹² Curiosity varies in degree among individuals according to certain personality traits⁷ and its triggers are also individual in nature so that two people might be drawn to different aspects of the same stimulus.

The adult learning literature proposes that curiosity and inquisitiveness flourish in an educational context that gives students responsibility for their own learning,¹³ that promotes multiple perspectives,¹⁴ that allows for mindful reflection on both the subject and the learning process itself,¹⁵ that encourages inquiry rather than simply supplying information,¹⁶ that creates a feeling of safety for the exploration of new cognitive and affective domains,¹⁷ that permits openness about uncertainty¹⁸ and that encourages students to work together with peers.¹⁹

Several theories of professional education hold that the development of capacities for mindfulness and reflection represents an essential bridge between trait curiosity and higher cognitive skills, such as problem solving, critical thinking and self-assessment. Reflection is a process in which learners step back after an experience in order to critically evaluate it in the light of their previous understanding and assumptions. It can lead to the development of reflection-in-action, thinking about what one is doing while one is doing it, which is critical to self-monitoring and ongoing learning.¹⁸ Mindfulness is the process of opening one’s attention to an event or experience while attending to both the cognitive and emotional responses it elicits in a non-judgemental way. It is thought to add vividness and clarity to the observations of those who are curiosity-driven, while directing them toward a deeper, more complex understanding.¹⁹

Suppressing curiosity

This paper will first explore how curiosity can be dampened by haste, the suppression of negative emotions, overconfidence and passive learning, each of which can be inadvertently encouraged in medical education. Efficiency is assuming growing importance in medical practice as a result of both the demands of third-party payers and the burgeoning of medical knowledge. However, the quest for efficiency can easily lapse into haste, an approach that can compromise attention to careful data collection, helping behaviours and decision making.^20–22 The potential of haste to subvert curiosity and empathy was demonstrated experimentally when seminary students, after preparing to discuss the story of the Good Samaritan, encountered a person in need placed en route to their lecture hall. Of those who had been instructed to hurry, only 10% stopped to help, but of those who had been told they had a few minutes, 63% showed interest and a desire to help.²³ The requirement to think and act rapidly, which is incorporated early in doctor training in the form of public drills, ‘one-minute precepting’ and ‘see one, do one, teach one’ exercises, can promote confusion between haste and efficiency and can dampen curiosity.

Curiosity is sensitive to negative emotions, such as anxiety or disgust.²⁴ In an effort to help the doctor maintain objectivity and rational thinking in a practice that can be highly emotional, medical education promotes the suspension of feelings. However, studies in cognitive²⁴ and neuropsychology^25,26 demonstrate that ignoring feelings in the quest for objectivity may actually interfere with rational thinking; feelings can be especially deleterious when they are unexamined or denied.²⁷ Clinicians have noted that the care of people with serious illness evokes intense emotions in doctors, which, if ignored, can have negative consequences for the quality of care provided, as well as for the well-being of doctors themselves.²⁸

Overconfidence can also be a barrier to curiosity. As part of their socialisation into the culture of medicine, students are encouraged to present an attitude of certainty and a veneer of competence, despite the findings of recent studies that have linked overconfidence to diagnostic error.²⁹ While it is important for doctors to feel confident and to convey a sense of competence to those in their care, many studies demonstrate that doctors show reluctance to acknowledge uncertainty to patients or peers.^30,31 Overconfidence can also discourage the pursuit of feedback and lifelong learning.⁴

Curiosity requires the opportunity to challenge convention and assumptions.¹⁴ Efforts to support best practices in medicine and to contain medical error through emphasis on protocol can inadvertently suppress learners’ opportunities to question medical knowledge. Teaching is typically conducted in hierarchically organised settings, such as lecture halls, or in ward teams that use top-down communication from an instructor-expert. Because expressing curiosity in these settings can involve risking criticism or humiliation, the learner often chooses to play a safer, passive role.³²

Nurturing curiosity

The suppression of curiosity in medical education is often an unintended consequence of the effort to teach important skills, such as efficiency, focus and emotional restraint. This section considers how classroom and clinical teaching can promote these skills while supporting curiosity.

Curious reflection requires having the patience to stand outside oneself, to critically examine one’s assumptions, and to listen carefully to others.^33,34 Expert medical practitioners learn when to switch from automatic processing modes to deliberative, reflective approaches. ‘Slowing down when you should’ is a key habit of surgeons who are adaptive experts.³⁵ Identifying and using brief ‘windows of opportunity’ facilitates listening to patients’ psychosocial concerns.³⁶ A few moments of preparation can help the practitioner engage better with the next patient.³⁴ Similarly, in educational settings, instructors might be cautious of rushing to cover breadth of content and, instead, focus on contextualisation, consolidation and application of knowledge,³⁷ allowing space for reflection and questions.

Freeing student curiosity requires medical educators to acknowledge the presence of emotion during the educational process. As role-models, they can demonstrate that feelings are inevitable but manageable, and that giving attention to feelings can even enhance recall and judgement.³⁸ Teaching itself can generate significant feeling in instructors who are invested in their work; it requires courage to avoid hiding behind the details of a subject or to tolerate the silences necessary to elicit the students’ voices.³⁹ The most student-centred instructors in medical education are those who are inclined to share their own feelings with students and who are non-defensive when encountering student feedback.⁴⁰

Instructors should recognise students’ overconfidence and redirect learners toward curious reflection. Medical practice is replete with complexity and uncertainty and students must learn to face these, within themselves as well as in patients and colleagues. To critically examine their own level of competence and to engage in lifelong learning, students must also learn to face information that might challenge their self-esteem and incline them toward self-deception.⁴¹ Skilled teachers recognise when students feel most vulnerable and provide them with unconditional regard that is distinct from the adequacy of their performance.¹⁷ Students who feel supported can cultivate a non-anxious presence, be more attentive to their patients and be curious if their initial impressions are wrong. One key way of developing an environment that facilitates this sense of support may be for instructors to demonstrate humility about their own understanding of their subjects, not as false modesty, but in recognition of the multifaceted and evolving nature of scientific knowledge.³⁹

Curiosity is supported by helping students formulate questions. Curious instructors create an openness that encourages students’ curiosity, especially among students who might withhold their questions for fear of appearing naïve. Research has shown that rewarding the formulation of incisive and insightful questions enhances the expression of diagnostic reasoning,⁴² thus promoting the acknowledgement of uncertainty rather than branding it as a sign of inadequacy.

Learning to formulate questions involves more than simply being given room to ask; questioning is also a skill that can be developed. Doctors can benefit their own diagnostic accuracy by developing a habit of asking themselves reflective questions.⁴³ Such questions might bear on how one’s emotions may be colouring perception, such as: ‘Is this patient irritating me?’‘Am I tired?’‘Do I want to get home soon?’ Reflective questions might bear on clinical reasoning, such as: ‘Does my diagnosis encompass all the available information?’‘Is this treatment approach working or do I need to step back and start over?’ Instructors can teach reflective questioning by thinking out loud: ‘I’m wondering if I covered that area adequately?’‘I feel some urgency to get through this material but wonder if that is the best thing?’

Lastly, instructors can support curiosity by harnessing its social nature, the fact that interest in the views of others is fundamental to survival and represents the foundation of collaboration.^8,9 Students’ curiosity is deepened and diversified when they interact with the views of others.⁴⁴ Problem-based learning and team-based learning (TBL) leverage this aspect of curiosity. Team-based learning has demonstrated impressive outcomes with regard to the depth and durability of participants’ learning.¹⁹ Both of these approaches broaden the student role beyond that of a recipient of information and make the student a peer educator as well. Conversely, this expands the instructor’s role of the subject specialist, who educates from the podium, to one that includes facilitating effective learning interactions. Instructors can model the expert learner by formulating their own learning needs and soliciting feedback.⁴⁰

Illustration

The approaches suggested here can be applied to a variety of learning contexts. For instance, in a session on prostate specific antigen (PSA) testing, an instructor used a TBL format, breaking the students into small groups of seven. As she began the conference, the instructor shared a personal self-assessment: ‘I’m trying to fine-tune my pacing in this TBL format, so please pay attention to how I use our time today; your feedback will be important to me.’ Explicit self-reflection can model how students’ own curiosity about their performance might help them learn to self-monitor and improve.

During the conference, the instructor assigned the small groups a task of formulating ‘the most valuable question for class discussion’. Focusing on questions rather than answers can challenge students to develop an attitude of inquiry rather than an intention to simply produce an answer. In the course of discussing this controversial subject, one group became interested in how to communicate the benefits of a low-specificity screening test to patients, and another wondered about the quality of design in the two studies they had been given to read. An approach such as this can enable students to deal with their frustration with the lack of clarity in recommendations regarding PSA screening by adopting an open attitude rather than demanding definitive answers. Not only can they absorb information about PSA for an examination, but they can also probe it, apply it and experience it on a personal level. By using techniques such as these, in a variety of clinical and classroom situations, instructors can stimulate curiosity, self-questioning and self-awareness.

Conclusions

If medical education is viewed predominantly as a content-heavy enterprise requiring the mastery of facts and skills, instructors and students will be drawn primarily toward producing answers and away from developing an inquiry-based learning that fosters curiosity and discovery. This paper has attempted to demonstrate that curiosity, inquisitiveness and related habits of mind can be supported in medical education through specific, evidence-based instructional approaches. Although medical education must address the realities of content learning and time constraints, it should be remembered that the practice of medicine always involves discovery and strong emotions, and is conducted in highly dynamic social environments. Doctors are more than technicians: they must have adaptive expertise, the ability to manage the unexpected.⁴⁵ Medical educators must balance the teaching of technique and protocol with helping students to maintain doubt, wonder and awe in the context-rich, uncertain and often ambiguous world of clinical medicine. Calls for self-reflection, critical thinking and teamwork become hollow in the absence of curiosity. The importance of seeing the world in multiple ways applies equally to the clinician-teacher, the basic science researcher and the anthropologist; it is the primary substrate of clinical reasoning, healing relationships and patient-centred care.

Contributors:  both authors made substantial contributions to the conception and design of this paper, and the drafting and revision of the text. Both authors approved the final manuscript for publication.

Acknowledgments

Acknowledgements:  the authors would like to extend their appreciation to Drs Barbara Birshtein and Norman Brier for their helpful comments on the manuscript.

Funding:  none.

Conflicts of interest:  none.

Ethical approval:  not required.