A couple of decades back, a senior surgeon handed me a scalpel, addressed me as doctor, and told me to make my very first incision. My hand and the knife then hovered over the patient's abdomen like a helicopter over a traffic accident before finally taking a timid swipe and barely scratching the skin. My colleague waited patiently for me to shake off my nervousness, and a couple of hours later, the patient and I—an intern—were both in stable condition in the recovery room.
Now I sit at my desk—a grid of PowerPoint slides on one computer monitor, my course outline on the other. I am a novice again, midway through the 28 lectures that I will present this spring. Only for the moment, I'm doing a lot of staring and very little PowerPointing, and the prospect of teaching an entire course for the first time seems far more daunting than performing surgery. Medicine is a teaching culture. Second-year students show first-year students how to throw square knots, interns give impromptu seminars on fluid management during quiet moments in the intensive care unit, and bow-tied internists happily demonstrate the secrets hidden in the patterns of filling and drainage of neck veins to the first orderly or flower-cart pushing volunteer who happens to walk by.
I left medicine a few years ago but continued to teach: an occasional hospital grand rounds where I had trained or lectured to science or business students. Now I agonize over decisions that experienced instructors take for granted. In a few weeks I will teach my "Entrepreneurship in Biotechnology" students the 10/20/30 rule of effective presentation: 10 slides in 20 minutes using a 30-point font. Of course, my first lecture has 33 slides, but I rationalize that the first few are throwaway office hours / grade consists of / last day for drop-add types. Lecture two has only five slides so far, but I need to leave time for student presentations. Each presentation should last one minute, followed by two to three minutes of discussion. Four minutes per student unless the discussions get detailed and deep—but what would be wrong with that? Nothing—but what if the discussion is superficial and belabors the obvious? Or what if there is no discussion at all, just the kind of sinking silence that happens in comedy clubs when the comedian completely loses the audience, and everyone knows that he can't win them back but also knows that he has to try and that they have to sit through it?
Tonight I struggle with week one. The slides are unformatted black on white, with a little line at the bottom with the course number and "Columbia University GSAS" in small font. The slides appear in neat rows across the screen, but their concepts and ideas somehow remain hidden—the presentation a puzzle with all the pieces the same shape and no clues as to their correct order. One of the business-world clichés that I will relate (though not necessarily endorse) is that a presentation needs to be delivered 25 times before it makes sense. I am unwilling to sacrifice coherence for my first 24 semesters, however, so I devise different practice methods. Most often, I lecture to two dogs in an otherwise empty room. Weeks one and two are almost ready, but week three is not even close.
My students-to-be are an extremely smart group: a mixture of undergrads, masters, and Ph.D.s in the sciences, hoping to cram as much of a business education as they can into one semester. I worry about letting them down. I focus on them and try to anticipate their expectations. I stop polishing my delivery and start listening for clarity. Suddenly the teacher's block breaks, and a few of the slides almost jump off the screen and beg to be moved elsewhere. Quickly, week three is almost clear—its transitions logical and its conclusions evident.
My process is evident as well: course outline on one screen, slides on the other, practice out loud in an empty room, dogs optional. Listen for what your students will hear, and make it logical for them to understand. Repeat as needed.
Ray Bradbury once said that living at risk is jumping off the cliff and building your wings on the way down. I used to think that cliff jumping was a young person's sport, but I still find myself walking along edges, blueprints in hand.
I arranged for BIOT 4180 to take their final exam on a survey site on the web. Half the class sat in front of me in Hamilton Hall; the rest took the exam wherever they wanted—dorm room, Starbucks, London. I activated the page at 4:00 and planned to close it two hours later. Not too pressured but not too easy. Every student had my email address and cell phone number if a technical problem arose.
I watched as the site tabulated the responses. The exam grew harder as it progressed but the percentage of correct answers stayed well above 90. As they had through the entire semester, my students exceeded my expectations.
The delivery log from my first night as an attending obstetrician lists two vaginal deliveries and a cesarean for a footling breech early in the evening, followed by my outcome code: HMHB—healthy mother and healthy baby. My role was to supervise the residents and the midwives. I remember thinking about the on-call room and sleep.
“Doctor Sable—in here. A shoulder.” Sleep would have to wait.
The room was old-fashioned, not one of those “birthing rooms” with flowered curtains and a foldout sofa. No, this was a real operating room. Thankfully. The shoulder was a young woman, first baby, pushing and breathing. The baby’s head was out.
And the baby was stuck.
At 4:45 the survey site instant messaged that it would terminate the exam in five minutes. A countdown clock appeared. I linked to technical support and typed “survey termination.” Technical support recommended I upgrade to “Pro” level for longer duration surveys in the future.
My phone rang. A little red circle appeared at the upper right hand corner of my computer mailbox: 2 messages. The countdown clock showed reached four minutes. The red circle showed 12 messages.
BIOT 4180 had 65 students.
Every oral board exam in ob/gyn includes a shoulder dystocia case, and every obstetrician can recite the steps: extend the episiotomy, press on the abdomen above the pubic bone, have the mother flex her hips and pull back on her legs, pass a hand along the baby’s back and press the front shoulder to an oblique angle, rotate the posterior arm in front of the baby’s chest and out.
Break the baby’s collarbone.
I muted the phone, googled “screen capture mac,” and email-blasted “Plan B coming.” I text-searched my hard drive for the words “final exam.”
A gown found my arms. Gloves found my hands. The apprentice midwife stepped aside and nodded. The baby was blue. I figured I had ninety seconds.
I extended. I pressed: nothing.
She flexed. She pulled: nothing.
I felt the back and rotated the shoulder, gently bringing the upper arm along to avoid fracturing it, just like the textbooks say.
The countdown clock read “0:25” by the time I had compared the draft copy of the final with what I had put on the survey site, updated it, cut, pasted, formatted it into an email (“Plan B as
promised”) and hit “send.”
I unmuted the phone.
I had never broken a collarbone, had never seen a doctor break a collarbone. I was one maneuver away from learning the hard way.
I felt for the posterior arm and gently passed it in front of the baby’s chest. The arm popped out. The back shoulder slid forward. The front shoulder slid under the pubic arch and the body landed in my hands. Blue face turned pink and the baby cried.
HMHB. Healthy mother. Healthy baby.
Sixty-five completed exam emails arrived, all completed within a time-adjusted two hours. My students, as usual, exceeded my expectations. I could only hope that I had met theirs.
David Sable MD
writer, teacher, fund manager and retired reproductive endocrinologist