Richard Smith: What have I achieved in six years of teaching?

richard_smith_2014Yesterday as I flew home from teaching in Amsterdam for the last time, I wondered what I might have achieved in six (or perhaps it’s seven) years of teaching.

Twice a year at the Royal Tropical Institute (KIT: Koninklijk Instituut voor de Tropen) I have taught about non-communicable disease (NCD) on the “tropical doctors’ course,” and once a year I’ve taught students on the health and development course.

Most of the students on the tropical doctors’ course are young Dutch doctors, but there have been some from other countries and some nurses and other clinicians. Many of them have worked or will work for Médecins Sans Frontières, and they are selfless and inspiring. Their clinical skills are supplemented by surgery, and the course does its best to prepare them for responding to all health problems in low and middle income countries and refugee camps.

The course has been running for many years, and on the wall are pictures of earlier generations of students—all men in suits with big moustaches. Now more than half the class are women. Until the year before I began there was no teaching on NCD, and it had been taught just once or twice by Jaime Miranda, a Peruvian friend. At the time he was doing a PhD at the London School of Hygiene and Tropical Medicine, and it was easy for him to cross to Amsterdam and teach. Once he returned to Lima it was impossible, and he suggested that I take over.

There had been no teaching on NCD because it wasn’t thought to be an important problem in low and middle income countries; and before the 1980s, it wasn’t. In my teaching I show a graph of causes of death in Matlab in Bangladesh: in 1986 NCD accounted for 10% of deaths, but by 2006 it was 80%—a very rapid transition. A pandemic of NCD is sweeping through low and middle income countries, so it became essential to have something about it in the course.

Similarly, it needed to be included in the health and development course, which lasts a year and is attended by students from a wide range of low and middle income countries but mostly from sub-Saharan Africa. The students are a mixture of doctors, nurses, pharmacists, and officials from health ministries. They are older than those on the tropical doctors’ course and usually harder work to teach; but the last class I taught yesterday had about 30 students and was especially responsive. There was one student—a woman doctor from Tanzania of about 35—who, even in the short time of the class, I felt sure will become minister of health if not prime minister in Tanzania.

When I started I felt vulnerable teaching the young doctors: not only have I never worked as a doctor in a low and middle income country, I have worked as a doctor seeing patients for only two years (and even then being essentially as assistant to “real doctors”). But I was told that didn’t matter: I wasn’t teaching them clinical skills, but rather opening their eyes to the importance of NCD and giving them information on its prevalence and courses, and discussing both global and local responses to the problem.

Teaching is, I believe, a branch of the entertainment industry. Nobody learns when bored. I’m also a great believer in the quote that I thought came from William Butler Yeats that “Education is not the filling of a pail, but the lighting of a fire.” But I learn from Quote Investigator that Socrates is said to have said two millennia earlier: “Education is the kindling of a flame, not the filling of a vessel.” In fact, there is no evidence that either made the quotes attributed to them, but Plutarch did write: “The mind is not a vessel that needs filling, but wood that needs igniting.” Whoever said or wrote it, I believe it strongly. I’m also keen on the phrase “All teach, all learn”: the students know much that I don’t know. I work too on the principle that the students already know much of what they need to know, and that it’s my job to help tease it out of them.

I’ve never had any training as a teacher, but this set of principles means that in six hours of teaching I try never to talk for more than 10 minutes at a time, and I mostly succeed. I encourage interaction and laughter, so I have to think a lot on my feet—and I am, I believe, performing rather like my brother, a stand-up comedian. It’s fun but tiring. On the tram to Amsterdam Centraal after my day’s teaching I sit like a zombie, staring out of the window. Once at Schipol I need a beer, even though it may not be 5 O’clock. I’m left hugely admiring of teachers who teach day after day. How do they manage it?

But what have I achieved? I’ve flown many miles, consumed much carbon, spent hours interacting with students, had great fun, and shared the 150 slides on my Powerpoint some 20 times. But is the world any better? Will the students be more effective because of my teaching? Will suffering be relieved, deaths averted, health created? I find it hard to believe that that will be the case.

But it could be. The nature, duration, and style of my teaching make it hard to know. I haven’t taught the students a skill that they can retain all their lives and use to great benefit. I haven’t filled buckets (I haven’t tried to), but could I have lit fires, fires that will burn and transform. I’ve taught around 1000 students, surely I must have lit at least one fire.

I think of yesterday’s Tanzanian doctor when we discussed how low and middle income countries, which have only embryonic health systems, have the opportunity to develop health systems that will be more sustainable than those we have in high income countries. I presented some ideas, and her thoughtful questions showed that she was very taken by the ideas. Perhaps she might feed that small flame, and the consequence might be a more sustainable health system in Tanzania.

A young Dutch doctor was taken by my talk about climate change being the number one health problem and asked to be connected to doctors I know who are leading the way on environmental sustainability. I connected her, and who knows what the consequences might be. Perhaps nothing, or perhaps a vibrant movement in the Netherlands that will contribute to real change.

Teaching is a privilege and a pleasure, and I enjoy it. As we discussed last night at dinner, we can all remember teachers who had a big impact on us: I think of Nigel Ballantyne, Len Morey, Mr Eliot, Bryan Mathews, John Munro, Stephen Lock, and there are more. Perhaps somebody will remember my teaching.

I think back to a dismal teaching session in Kumasi, Ghana. In the evening we ate dinner outside, and I expressed my dissatisfaction to the dean of the medical school who sat next to me. “But who knows,” he said, “you may have planted an acorn that will grow into a great oak tree.”

Richard Smith was the editor of The BMJ until 2004.

Competing interests: None declared.