This is the time of year I get ready to precept a group of third-year medical students. We have four weeks together on the medicine wards, and while they constantly worry about the facts, I worry about how they think. Teaching my students clinical reasoning means helping them harness their most powerful diagnostic tool – their ability to communicate effectively and compassionately. Better communication not only betters health, especially for people with chronic illnesses, but also makes doctoring more satisfying.
Medical schools have developed a host of innovative programs to improve this skill, but as far as I know, none has proposed my fantasy solution – asking students to trade their white coats and stethoscopes for striped shirts and whistles, so they can referee soccer. Though this may seem strange, I have learned over the years that good refereeing is a lot like good medicine.
Soccer was my game growing up, and when my son joined a local youth team, it rekindled my fervor. A full-time medical practice left me little time to coach, so refereeing became my way to watch him play and inoculate him against my touchline antics. The fact that it improved my doctoring came as a surprise.
A game is alive; it is moving and pulsating, and there is the ever-present danger of injury. In the midst of all this is the referee, singularly bestowed with the duty to "enforce the laws of the game". Some of the laws are direct and quantifiable – a pressure gauge can verify proper ball inflation. Others, as when, precisely, does a player in an offside position become active, are delphically abstruse. Most are neither, but all require constant vigilance and split-second judgments.
The art of refereeing, like the art of medicine, requires not just a thorough knowledge of the laws but the craft to intervene wisely. I am not shy about making decisions – few doctors are – but stopping play for every misdemeanor destroys the flow and frustrates players and parents. Some of my son's teammates still wish that for my first few games, I had a whistle inscribed with "first do no harm".
The laws also dictate that as referee, I have "full authority" and that my decisions "are final". They do not, however, suggest reciting this to players unhappy with those final decisions, unless resentment is the objective. When I see a colleague do just that, I wish I could whisper what I was taught at my first refereeing class: while the laws cede us full authority, they also prescribe that, during play, our status is the same as a goal post. The referee is part of the field, in service to the players who are there to have safe, competitive fun.
This is familiar to me. In my office, I make diagnoses and prescribe treatments, yet it is my patients who must undergo tests, digest pills, and heal their wounds. Disease is not about the doctor, in some of the same ways that the game is not about the referee. We are sheltered in some midway place – a limbo of neither true observers, nor full participants.
Doctors and referees must also continually balance authority, the right to order and be obeyed, with autonomy, the right of a patient, player or spectator to do what they wish: a task made even more challenging by the press of constant decision-making and the desire for irreproachable accuracy. Under these conditions, even innocuous questions can become the affront that leads to wielding a yellow card or writing a prescription with the admonition to "just take this". I want my students to be conscious of these pressures to avoid the path of least resistance that decays compassion and turns the tools of authority into cudgels of power.
Clear communication and respect helps, at least until the first mistake. A mistake changes everything.
As a rule, we doctors do not embrace mistakes naturally. Our training deifies perfection, and I see that my students are its newest disciples well before they have even touched their first patient. Mistakes seed shame and defensiveness that crystallize into arrogance, transforming the doctor from ally to adversary. Add to this the way the most vulnerable often need to believe that their doctors are infallible, and suddenly, mistakes become cataclysmic.
Refereeing has been my laboratory for learning how to uncouple fallibility from failure. I approach each game like a student preparing for rounds – dutifully re-reading the laws of the game, scouring "you are the ref"-like websites for answers to staggeringly improbable scenarios, and making sure my contact lenses are in. Sacraments which I hope will help me be rewarded for my accuracy, but chastened by the knowledge that, without fail, I will make mistakes. All will be public and many will be sharply pointed out to me by both the players and their supporters. In addition, unlike my office where patients and their families bear some unspoken natural belief in my precision, the pitch is a mirror universe where even the right calls can meet with rebuke.
At first, this led to forays into self-pity over the injustice of how could I always be wrong. This lasted almost a full season until a professional tower crane operator liberated me from my indignation. My accidental emancipator came up to me after a game to tell me that, even from where he stood, at the other end of the pitch, it was obvious that the ball had fully crossed the goal line into the net; my failure had denied his son a sure goal.
I left the pitch astounded, but soon began to assess the geometry: what is the angle of view for a man, approximately 6ft tall and 80 yards away? Could his eyes actually have discriminated between the ball and line? Thankfully, before excavating my old math textbook, I realized that my determination to comfort myself had just given me a lift up to a perch overlooking my own magical thinking. Checklists, proper positioning, better concentration or whatever new strategy I might dream up … none could never make me error-free. Mistakes are more than inevitable; they are part of the basic currency of human relations. Their pain and the recognition of a shared vulnerability can be a connection more intimate, perhaps, than shared joy .
This realization freed me from both the sideline clamor and my fantasy of perfect accuracy. It became clear that the fullest expression of authority depends more upon a facility to address mistakes than a fidelity to precision. Without that, it just becomes the use of force. And though it was still agonizing, when I had to face my son's team and apologize for denying them the stone-cold penalty that could have helped them win, this new understanding bolstered my ability to do it without fear or shame and with a full heart.
Recently, I took this lesson I learned on the pitch into my office. I failed to diagnose temporal arteritis, a common and potentially devastating illness, in a patient I have cared for since starting my practice. When I sat with him to talk about it, clenched arms and a taut gaze spoke of deep anger and disappointment in me. The disappointment was more unsettling than any distant thought I had then about a possible malpractice suit or losing him as a patient.
I knew from my refereeing that listing excuses – like how atypical it was to have temporal arteritis without fevers, or weight loss or abnormal blood tests – was irrelevant; the truth was, I had not even considered the diagnosis. Without equivocation, I said that I made a mistake and knew it was damaging. I acknowledged that he might never be able to trust me again because my failure might haunt him. I silently confessed that it would haunt me, too.
We spoke for some time and I answered his questions as best I could. After parting, I was shaken but also comforted by an unexpected realization: the direct acknowledgement of my error was as important as any medication in healing my patient.
Some doctors rate their success by the number of famous patients they treat, or the rare illnesses they have diagnosed, but for me, I count that moment with my patient as one of my real successes. Refereeing illuminated the path that brought me to this broader understanding of what good medicine and good care means. So, this year, though I won't take my students onto the pitch, one goal of mine will be to make them better at making mistakes, too.
