commentaries
Aultman J, eds. Professionalism in 10 Wear D. Privilege in the Medical
Medicine: Critical Perspectives. New
York, NY: Springer 2006;149
61.
Emotions in learning is more than merely learning of
emotions
Lambert Schuwirth
As I read the material to be
included in this issue of Medical
Education, I found myself suddenly
thinking a lot about my own
clerkships. My first, in internal
medicine, included 2 weeks on a
respirology ward. I remember one
patient in particular, an elderly
woman who was ready to be dis-
charged. She was terribly happy
about going home. Unfortunately,
she could not express this because
a massive stroke had left her with a
complete aphasia. Hearing from
her daughter that before the
stroke she had been an erudite,
intelligent and well-read woman
made me sad for the cruelty of her
situation. When the senior
registrar told her she was about to
be discharged, she could reply only
by gently stroking his cheek to
thank him. His reaction on the way
out hit me like a sledgehammer:
Well, it is more like veterinary
medicine this way, isnt it? I have
castigated myself ever since for
not speaking out and telling him
his behaviour was arrogant,
pompous and self-absorbed, but in
Adelaide, South Australia, Australia
Correspondence: Lambert Schuwirth md, PhD,
Flinders Innovations in Clinical Education,
Flinders University, GPO Box 2100,
Adelaide, South Australia 5001, Australia.
Tel: 00 61 8 8204 7174;
E-mail: lambert.schuwirth@flinders.edu.au,
lambertschuwirth1@gmail.com.
doi: 10.1111/medu.12078
14
11 Bleakley A. Gender matters in
Academy: A Feminist Examines Gender,
Race and Power. New York, NY:
Teachers College Press 1997;33.
retrospect I have come to see that
the power difference between the
registrar and myself was just too
great.
This is only one of the many inci-
dents which taught me quickly
enough that learning medicine,
especially during practical training
periods, was about survival. Keep-
ing a low profile, staying out of
trouble and trying not to get too
damaged were successful strategies;
showing your weaknesses was noth-
ing short of career suicide.
The power difference between the registrar
and myself was just too great
Perhaps by now you think I am
overreacting, but as you read the
paper on memorable professional-
ism-related dilemmas by Rees et al.,1
published in this issue of the journal,
you will find that in the over 20 years
since I graduated, not much seems
to have changed. Apparently these
incidents still occur at a prevalence
sufficient to warrant study. The only
thing to have changed is that the
study and remedy of this painful
educational problem now require
the approval of about 30 different
ethics review committees, whereas
the creation of these dreadful, dam-
aging situations demands the formal
ethical approval of none.
Blackwell Publishing Ltd 2013. MEDICAL EDUCATION 2013; 47: 317
medical education. Med Educ
2013;47:5970.
Learning medicine, especially during
practical training periods, was about
survival
In addition to the personal damage
caused to students by such incidents,
I feel they also refer to a general
educational issue concerning the
development of programmes for
assessment for learning. I see such
assessment-for-learning programmes
as representing a sine qua non in
ensuring that we educate our stu-
dents to become the self-directed,
lifelong learners they very much
need to be. I have never been able to
understand how, if all assessment is
instigated by the school and its
faculty staff, and has only a punitive
connotation (we are going to prove
that you are not good enough; you
are the proverbial bad apple), we can
ever expect our graduates to become
self-directed, lifelong learners. How
can they if they are never given an
opportunity to actually practise this
during their training? However, the
attainment of such programmes can
be likened to reaching for pie in the
sky if we do not manage to change the
culture of learning and assessment.
If the purpose of assessment or
testing is only to demonstrate that
one student is better than another,
then the assessor and assessee are
necessarily adversaries. If the pur-
pose of assessment is to help make
each individual student into the best

possible doctor he or she can be, it is
much easier to orient the assessor
and assessee towards a shared goal.
Needless to say, remarks such as You
there the decoration, cited by Rees
et al.,1 dont really help.
Assessment-for-learning programmes rep-
resent a sine qua non in ensuring our
students become self-directed, lifelong
learners
Studying the role of emotions in
education is therefore important:
firstly, because we simply need to
refrain from harming or damaging
our students, much as we need to
refrain from harming or damaging
our study subjects in research, and,
secondly, from a more abstract
educational point of view, because
emotions are important in more
ways than merely as physiological
responses, as Nancy McNaughton
emphasises in her paper Dis-
course(s) of emotion within medi-
cal education: the ever-present
absence2. The impact of emotions
surpasses the level at which we refer
to the skilled use of emotions in
patient care and communication
with others because they are so
tightly connected to the social
contract and our culture. They are
mediators in communication about
those issues in medicine that are so
important but so difficult to delin-
eate, where medical science is not
about what is true, but, instead,
what is right.
Emotions decide what a student
wants to learn. We all know that we
can make students study, using
testing as the proverbial whip, but
this does not equate to making
them learn. The latter requires a
Blackwell Publishing Ltd 2013. MEDICAL EDUCATION 2013; 47: 317
true understanding of the emo-
tions involved in learning and
focusing on the fun factor and
consumerism is not a viable
substitute. Emotions relate much
more to the meaningfulness of
learning than to fun.
Emotions are mediators in communica-
tion about those issues in medicine that
are so important but so difficult to
delineate
Emotions also establish what a
student dares to learn. Learning is
associated with friction, with being
pushed out of your comfort zone,
with understanding that your cur-
rent view on how things are does
not align with new information.
This is both exciting and
frightening: anybody who has been
exposed to completely new
challenges will recognise how both
of these powerful emotions occur
in tandem.
Perhaps more importantly, emo-
tions decide what a student wants to
forget. Forget the dull stuff that
had no meaning, but that you were
required to learn for the test. For-
get it because it did not make you
curious, critical, investigative or
scholarly and, above all, it did not
make you interested. This learning
has been a waste of time, even if the
material was relevant, because the
emotional aspect of learning was
not used to its capacity.
Learning is associated with friction, with
being pushed out of your comfort zone
commentaries 15
Finally, emotions decide what stu-
dents do NOT want to forget.
Things that we cherish because they
made us curious, dared us to
contradict, made us want more
information are not forgotten.
Thus, I am afraid that I apparently
did not want to forget the incident
I described at the start of this
commentary because it taught me
something. It taught me that short-
sighted arrogance is good for nei-
ther patient care nor education.
I have since learned that we should
not try to teach our students to
speak out in such a situation: the
power gradient is indeed too steep.
Instead, we can challenge them to
learn from such events so that they
become able, for example, to
maintain their own integrity in a
cynical environment and to educate
their own students.
Overall, although these incidents,
in combination with the impact of
the various great positive role mod-
els I have observed, have probably
increased my resilience, I cant help
wondering what kind of doctor
I might have become in a more
nurturing clerkship environment.
REFERENCES
1 Rees CE, Monrouxe LV, McDonald
LA. Narrative, emotion and action:
analysing most memorable pro-
fessionalism-related dilemmas. Med
Educ 2013;47:8096.
2 McNaughton N. Discourse(s) of
emotion within medical education:
the ever-present absence. Med Educ
2013;47:719.
15