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Learning Paths Podcast
Richard Schwartzstein

Richard Schwartzstein, Harvard Medical School and HMX Physiology faculty

Dr. Richard Schwartzstein has had a long, diverse career as a physician and educator, with several current roles at Beth Israel Deaconess Medical Center and Harvard Medical School, including leading the HMX online physiology course. In this episode of Learning Paths, he speaks with Dr. Michael Parker, HMS associate dean for online learning and faculty director of HMX, about his professional motivations and the unique challenges and rewards of teaching both in the classroom and online.  

Episode Transcript

Michael Parker: This is Dr. Michael Parker. I am associate dean for online learning at Harvard Medical School and faculty director of HMX, and it is my great pleasure today to be talking to Dr. Richard Schwartzstein, who is, has multiple titles. He is chief of the division of pulmonary critical care and sleep medicine at Beth Israel Deaconess Medical Center. He is professor of medicine at Harvard Medical School. Also vice president for education at Beth Israel Deaconess Medical Center. And then additionally he’s executive director of the Shapiro Institute for Education and Research at HMS and BIDMC. I also have to say that Rich is a, has, for a long time, been a friend, a colleague, and a mentor. So it’s a really special treat for me to get a chance to sit down with you, Rich, today and talk to you.

Richard Schwartzstein: Well, thank you, Michael. It’s great to see you as always.

Michael Parker: So maybe just starting out with a little bit of your background for people who might not be familiar with you. How did you originally decide to become a doctor?

Richard Schwartzstein: Well, it wasn’t from the very beginning, interestingly, I actually thought I wanted to be an aeronautical engineer as I was growing up. And you have to remember that as a teenager, I got up in the middle of the night to watch the moon landing in 1969. And so I was really fascinated with that, as so many young people were at the time, thought I wanted to be an engineer. And then interestingly, my father got a really severe case of pneumonia and had to be hospitalized. And so I started reading about pneumonia and various things going on with him at that time medically and thought, you know, that interesting as engineering is, the human body is even more fascinating to me. So that kind of took that initial thought process around engineering and building things perhaps, and how things work I guess maybe is even more important, and then just transformed that over to biological systems as opposed to mechanical systems.


Michael Parker: And, you know, one thing that I’ve seen is that you know, you’ve been an educator practically from the start of your career, and I’m very curious, what drew you into teaching? Was that something that kind of came naturally, or is that a transition that you decided to make at some point along the way?

Richard Schwartzstein: Yeah, it’s an interesting question because when I look back in retrospect thinking about, say, college, for example, or even getting into medical school, I don’t know that I thought a lot about teaching, frankly. The Hippocratic oath, of course, which all medical students do at graduation includes a line that’s very noble about continuing and contributing to the ongoing legacy of medicine and teaching the generation after you and honoring those who taught you. And it’s a wonderful ethos. And I think that’s probably when I first started to think more about that. And of course, as you go into your training after medical school and you become an intern and then a resident, you’re training medical students, so you become a teacher just as part of the process of your own training.

And then I had the opportunity to be a chief medical resident. So that’s a single resident who’s selected to then oversee all of the trainees, in this case in the department of medicine, which is where my training was. And that’s where I really started to focus more on teaching and how best to teach. And I didn’t know a lot about education in terms of educational theory, particularly, but you know, I started to observe really good teachers, people that I thought were good teachers and started to copy things that they did or borrow things that I thought would work for me. And then when I came on the faculty in 1986, I would do clinical teaching the way most doctors do, again, kind of in the spirit really of Hippocrates, until about 1996 with 10 years on the faculty, and they were redoing the physiology course at the medical school and taking it away from the basic scientists, sort of laboratory physiologists, and giving it over to clinical physiologists.

And I was doing research at the time in physiology, clinical research. And so they said, would you mind redoing the respiratory portion of the physiology course? And I said, this sounds like an interesting opportunity. So I took that up and at about the same time I was living in the town of Wellesley, which is about 12, 13 miles west of Boston. And I have four kids and they were in the school system, public school system. And I thought, you know, if I’m not happy with the schools as much as I might be, I need to take ownership. And I ran – it’s an elective position – I ran for school committee in 1996, just fortuitously at about the same time I took on this new teaching role. And I got elected to the school committee and spent six years in this position overseeing, with four colleagues from the town, the public school system. And I chaired the committee for three years, which brought me into really close contact with the superintendent of schools, the director of curriculum, and started to learn from, train educators, which really, I think, accelerated both my interest in learning more about education theory and teaching as well as just getting more information and knowledge from them as well.

Michael Parker: That’s fascinating. So the getting involved in the education of your children and your community fed back into your other teaching, is what it sounds like.

Richard Schwartzstein: It was, but it was an interesting blend of my science background with this net-new interest in education, because I would ask about, well, tell me the data that supports something that they wanted to do, or some new curriculum coming down. And more often than not, there weren’t a lot of data, but I would push for it. We would analyze it. We would talk about it. And as an elected official, you often have budgetary implications for whatever you’re doing. You have to then sell that to the town in terms of the budget. And so having a data-oriented background and ability to talk about data really was helpful as a sideline to what I was doing here that I could then convince them about – for example, why we should start teaching foreign language in elementary school because of the plasticity of the brain, and looking at the data on that and the ability to acquire a new language, and things like that made a big difference in how the town responded to some of our initiatives.


Michael Parker: One thing I really wanted to ask about, because you teach in a variety of different settings, are what are all the settings in which you teach?

Richard Schwartzstein: Well, the joy of starting to teach at the medical school in the first year, of course, first-year medical students in my course came about halfway through the first year. They’re not that different from lay people. I mean, they’re brand new into the medical community. And so it was a way of thinking about how I start communicating with my patients. You know, I’ve been doing that for years and this wasn’t necessarily that much different, taking difficult concepts and taking it to the level of a lay person, although they had a better science background than most of my patients did, of course. But that brought me into the classroom. It also brought me into a lecture hall. I still remember the very first time I had to speak to 165 Harvard students in this amphitheater, the way you see the old pictures of medicine being taught even before they had sterile facilities and operating rooms, you know, and there’d be all these people peering down in the operating theater and what was going on.

And that’s the way the lecture halls were – a similar kind of a pitch to the rows of students and so on. And I remember standing there in front of these 165 students, and I was really scared. I mean, it just was, seemed very daunting to try to now convey, you know, this physiology to these students. And, you know, I often say that to people who say, well, I’m this quiet person, or I’m afraid of speaking in front of groups and, you know, you just have to do it. And you have to say that we are all growing, continuing to grow. And even if you are a quiet person, a reserved person, whatever – I had no acting background, I played an instrument growing up in high school and college did a little bit of performing, but it was always in the context of a band or orchestra, it wasn’t solo kind of stuff – but we can continue to grow and develop.

And I started to get comfortable with that. And then I started to play with it, which was really a lot of fun. And I talk now and I do faculty development about how to do lecturing and I talk about it as a performance art. And that doesn’t mean you have to be a great comedian or something like that. It’s not that kind of, but you are performing, you are engaging the audience the same way a performer has to do that. And so I started to get more comfortable using body language and gesturing and inflections of my voice and making fun of myself and doing all sorts of things, anything in the, in the spirit of getting the point across to a student. And so that freedom to begin to play with things was, was very liberating for me. And and, and really became much more fun as well, just in terms of the whole teaching process.

Michael Parker: And, just to draw on that, it is obviously considerably different to teach online asynchronously, you know, like what we’re doing with HMX. How do you draw from, there’s this performance aspect when you’re there present with students and you’re getting direct feedback. I’ve been struck by how you bring some of the same excitement to the online setting. How do you fluidly transition like that?

Richard Schwartzstein: Yeah. It took time. I don’t think I could do that if I’d had to do some of the HMX stuff, for example, after I’d only been teaching for five or six years, but I’m able to almost imagine the audience and get that same energy and that same motion, motivation and connection to them.

And of course the other type of teaching that we all do all the time in medicine is clinical teaching, which is at the bedside. And there, of course you have the patient as well. And people are often uncomfortable teaching in front of a patient or worried. Is it going to feel like we’re making fun of the patient or doing something that’s not appropriate? And there have been studies that show that patients enjoy the teaching while they’re there in front of them because they like the attention and they like the fact that, wow, you’re really thinking about my case and you’re going through this. Now you get the permission to the patient, say, you know, I have some students with me or I have an intern with me and we’d like to talk about your case. I’m going to be doing some teaching.

And of course I always tell the patient, if you have any questions about anything I say, please ask, and I will be happy to explain it to you in a little more language that might be better for you, but I’m going to be teaching them about your lung sounds or your heart sounds or why your blood pressure is doing what it’s doing. And of course, you’re also at the same time modeling for the learner, how you interact with a patient. And that becomes an extra bonus for me as a teacher, because training a physician is more than just the knowledge, there’s how you apply it to solve problems, but there’s also that human element of interacting with the patient.

Michael Parker: Yeah. And I also think there’s a certain, maybe intellectual honesty to be able to explain something very clearly for a range of audiences. And in that setting of rounds, for example, in the hospital, you know, you have audiences of residents, medical students, the patient themselves, you know, there, I think that’s a special gift to be able to translate something into ways that multiple people can understand.

Richard Schwartzstein: Well, not only that, but, but it is a classical one-room schoolhouse. And sometimes while you may be focusing on the youngest learner in the group, you have to keep the older learner or the more advanced learner engaged as well. So sometimes you’ve got to either throw a question out that’s more advanced to the, a senior learner, or even better, sometimes you ask the senior learner to explain a concept to the younger learners. So you kind of engage the senior learner as a co-teacher in that situation. And on one hand, you’re observing whether they actually understand things at a deep level, and can they explain it simply to the early learner and you’re being able to give them feedback on their teaching skills as well as potentially their own knowledge, understanding of that concept.

Michael Parker: I also wanted to ask a little bit about, I know there are certain themes or ideas that have come in, regardless of whether you’re teaching in the classroom or online or at the bedside. And so what I’m talking about is ideas of things like critical thinking, of cognitive biases and how to look at those, and then also deductive reasoning and sort of that, that thread of logic. Can you touch on some of those and how those have factored into your teaching?

Richard Schwartzstein: Yeah. I think part of my love of physiology and maybe my engineering interests, even before I decided to go to med school, was solving problems. And now particularly with technology, everybody carries a computer in their pocket and, you know, in these iPhones and other versions of those computers that we all carry around with us, I think are supposedly more powerful than the Apollo spaceships, you know, that went to the moon. And so it’s really daunting to even think about that. So finding facts is easy. And yet when I went to medical school, well before that kind of technology was around, you know, you just felt like med school was memorizing a ton of information, and nobody likes to do that. That isn’t very much fun. And I always got excited. One of the reasons I think I love physiology, cause that was more of a problem-solving and conceptual field that I could get really wrapped around.

But as the technology came, we were still teaching very much in the old fashion, you know, here’s this content transfer. And so I started to say, no, that’s, that’s the easy part, you know, give people things, they can find the facts and the information. They can learn that easily, but it’s the solving the problems. That’s the hard part. And that means critical thinking. And so I started to get into that and then, you know, came across work about system one and system two thinking and the work of a Daniel Kahneman and Amos Tversky, and it really resonated with me about how we do this, how our brain works and how unconscious so many things are that have an impact on what we do.

And, you know, a lot of people say we can’t teach people to think – they’re either born with it or they’re not. And you know, you can’t do that. And I’m like, I don’t think so. I think you can actually teach people that. And so that became really what has been 20 years in the process, kind of working now of trying to figure that out, trying to find the best methods for teaching thinking skills, per se. All of us in medical school historically are taught something called the hypothetical deductive process. So without getting too technical for the audience, but the idea is that you get a little bit of information about your patient, getting some pieces of history or physical exam, a lab test, and you immediately are asked traditionally in medical training, what’s your differential diagnosis? And so you take these little pieces and what you’re taught,
it’s often not given the name when you’re learning it, but it’s the way educators talk about it now, an illness script. You know, if I find these three, four or five pieces of information that is most likely diagnosis X, so that becomes your hypothesis in a sense, this hypothetical deductive, you get a little bit of information and you hypothesize, if you will, a couple of diagnoses. That’s your differential, as the lingo goes, and then you deduce what you know about each of those diseases. So this has these five things as, as these eight things, whatever, then you take your patient and you kind of line up what they have in terms of history, symptoms, things on the physical exam, their labs, with whatever the three or four things is it’s in your differential, and the best match. That’s what you go with now. What if that’s all you could think of were three things and the actual diagnosis isn’t one of those three things? Well, you’ll never figure it out until, you know, just make mistakes on your patient or they don’t get better with whatever treatment you give them.

And so that was limiting. And of course there are these so-called cognitive biases, which I define as a predisposition to respond in a particular way as a generic term for what are cognitive biases. And so, you know, if the last case you saw was diagnosis X, you’re just more likely to think about that. Particularly if you made a mistake and you missed that diagnosis. Now you’re going to be thinking about that diagnosis a lot on the next 50 patients you see. And so these things can get you into trouble. So it was like, how do we do things differently? And I would start to think about, well, I don’t want to know what the answer, I don’t know what the diagnosis is, or I don’t want to know about that. I want to think about that too early. Rather, I want to think of what’s actually going on with the patient.

What do I know about the physiology of the patient? So in other words, if the patient is short of breath, well, there are a lot of diseases that can cause shortness of breath, but I don’t want to worry about that yet. I want to think about what’s the physiology of shortness of breath. Now let me work with those mechanisms of disease. If you will, the physiology, the pathophysiology, and then find out a little bit more about the patient and how those facts will change the way I think about the physiology. And then ultimately, yes, I’ll link that physiology to a diagnosis. And that’s more of an inductive approach, working from the particulars up to a general answer, if you will, which is a diagnosis that would explain all those things. And that’s when I have talked about this to general educators and audiences, it’s always been interesting to me that invariably, there’ll be some engineer in the audience, you know, a doctor who was an engineer in college and they’ll say, you know, that’s what they taught me when I was learning to be an engineer.

So maybe that was again, the link, my early interest in engineering and the way engineers perhaps think, and then what I’ve then taken to medicine.

Michael Parker: So first of all, guilty as charged in terms of, I’m a, you know, originally an engineer before becoming a doctor. So this is, I have to admit that was one of the big shifts for me in going into medicine, was coming from this very deterministic or mechanistic, or sort of derivation approach to something more nuanced, you know, which is really basically combining mechanisms with induction, you know, I think, and which is really at the heart of what you’re talking about which is just so important to medicine because the patient and the, you know, the disorders and the complexity of people’s lives really make diseases multifaceted, and the way they affect different people. So I definitely appreciate that. One thing you touched on basically was assessment. And so one thing I wanted to ask about is how do you, how do you determine if people understand what you’re teaching?

Richard Schwartzstein: Well, that’s a great question. And I think we fool ourselves a lot as teachers. One of the things we, one of my mantras, if you will, when I’m talking to faculty, is that we confuse what we teach with what students learn. Because I said it, because I showed a PowerPoint slide, because I demonstrated something, they may or may not have actually learned what you thought you were trying to convey. And so to me, it’s always important to figure out that they can do this on their own, in a sense; they can use this information and solve problems with it. And so I’ve always tried in my own courses to use assessments that get at that understanding, which often means open-ended questions related to a problem in medicine.

It’s easy to say a case of some kind and what’s going on in that patient. How do I explain what’s happening? It makes it really challenging to grade things because it takes a lot of time, challenging in the sense that faculty don’t like this as opposed to multiple choice kinds of questions. But I think it really gets at what the students know about a particular topic. And, you know, the most challenging thing in education at all, at any level I believe, in any content area, is what educators talk about is transfer. You know, you learn something in a context and learning is often context-specific, but then you encounter a problem in a different context. And it actually may be the same problem, or at least dependent on the same conceptual framework, but the learner doesn’t realize that, or can’t perceive that. And so they’re like, I don’t know how to do this problem. And for me, the big challenge is to get the learner, to be able to perceive that the fundamentals of that problem rely on the same concepts as the problem they solved yesterday.

And they actually do have the knowledge and the skills to solve this new problem. And so that’s another benefit, I believe, of learning in this inductive method. You know, I often say to them I don’t know the answer to this problem, but I know how to think about this problem. And, and we do that again. One of my favorite stories that I use, and I think Michael, you’re familiar with this, this anecdote, but just to share it with the listeners here. The movie Apollo 13, which is now a dated movie for many people, but it comes around on cable a lot. And so what about the true story? One of the failed moonshots, where an explosion occurs in the capsule on the way to the moon and they’re losing oxygen, and carbon dioxide’s rising in the capsule, and they have a scene where they’re showing mission control and the lead engineer, you know, is walking around and it’s just chaos. And most mission control people are running around like crazy and shouting at each other. And the head of the mission control says, I want you all to quiet down. And he finally gets there and says, I don’t want guessing, guessing makes things work worse. I want you to work the problem.

And I’m thinking, he’s not telling all these highly trained, sophisticated engineers that they’re guessing at answers, but they’re thinking about the first thing that pops into their head, and they’re susceptible to those cognitive biases. And what he was saying is don’t guess, don’t worry about the first thing. Don’t even worry about the end story of what the solution is, but start with basic principles of what the problem is on the capsule and what do they have available to them to solve that problem, and how do you go about fixing it? And so often when I’m in a classroom or I’m in the clinical area, and I ask a question of a student or a junior doctor, and they say, I don’t know. I said, you know more than you think. Now let’s break it down. Let’s break down the problem, and you tell me what you know about low oxygen, low blood pressure, pain in the chest. What do you know about that? Don’t worry about the solution to this. Just tell me what you know about the problem and we’ll work from that. And then when we go through this for a couple of minutes and they give the answer and this big grin comes across their face, usually, and I say, see, you knew it all along.


Michael Parker: That’s a terrific lesson. And maybe just to apply that, currently, obviously there’s a pandemic going on. You happen to be chief of a pulmonary division at a major hospital. How has this form of learning and adapting and you know, the way you think about problems helped you or affected what you’re doing during the pandemic?

Richard Schwartzstein: Yeah. The pandemic’s been horrible. Obviously there’s so many ways for so many people and so tragic with the number of deaths, but if there’s a silver lining at all, there actually was one with respect, I think, to clinical teaching in some ways. And the issue was that as physicians…the old story that half of what you learn in med school is going to be proven wrong in 20 years, we just don’t know which half. The challenge of medical school. But we have to be lifelong learners. We have to be often self-directed learners. And it isn’t just about knowing how to find facts and information again, but it’s how, knowing how to ask the right questions. And so the silver lining part of the COVID pandemic was none of us had seen this before – the teachers or the students, the senior doctors, the junior doctors, and we were all learning and exploring what we did know, trying to transfer knowledge from other diseases that look similar perhaps to COVID. What is similar? What is different? How do we learn from this? How do we adjust to it? And we were able, I think, to model for the junior doctors and the students, the way that thought process should occur, the way that you try to solve a problem you have never seen before using information that you have in other contexts. And how do we try to build on that? The other thing that was really, I think, wonderful was that people were often jumping to conclusions. They were affected by cognitive biases. They were missing using data, frankly, when all we had were, you know, my last case, I gave them this and it seemed to work. So I’m going to give this to every patient now. And I’m like, well, do they get better because of what you did or despite what you did? And so the sort of evidence-based rational, scientific part of being a doctor was disappearing in the pressure, if you will, to do something that might help people.

I mean, it was well motivated, but by the same token, I think we were very much at risk of interpreting anecdotal experiences and then generalizing to, Oh, this is what we need to now do, and potentially harming people at the same time. So I even wrote some papers that got published about just that, about the problem of cognitive bias, of recall biases it’s called, and anecdotes. And all of this sort of thing was potentially harming patients. So we were learning side by side and it gave me the opportunity at a local level and even at a national level to remind all of us. And we all needed the reminder at times that, wait a second, we’re learning here together. We need data, we need randomized trials. We need all of that sort of stuff before we draw conclusions about how to treat the next patient or the next 50 patients that we might encounter.

Michael Parker: It’s great that you’re able to link that form of learning to actually benefit the treatment of patients like this. I think people are much better off for that. One thing that I’m wondering about, because you’ve been teaching for such a long time, is what drives you to change your teaching from year to year? One thing that I’ve been struck by is that you’re not complacent and that you’re willing to try out different things rather than kind of just try, you know, you say this worked, let me try it again. You know, rather you’re constantly evolving. How do you think about that?


Richard Schwartzstein: Well, I think it’s, again, maybe similar to medicine, you know, where medicine’s always changing. And one of the things I learned when I was on the school committee in Wellesley, you know, some teacher would retire after, you know, 30 or 40 years of teaching and there’d be some little reception for them. And you know, people would gather in the back of the room, they’d say, well, that person taught one year 30 times, you know, versus the really good teacher who had taught 30 years, which meant every year, they taught a little bit differently. They learned from their prior experience. And that kind of resonated with me. And I always thought about that. He kept that in the back of my mind. I don’t want to be stagnant. I don’t want to be stale, I can always do better.

One of the things, particularly teaching early learners, who, again, don’t come in with a lot of preconceived notions about things, is that whatever explanation you have for something, it doesn’t always resonate with that learner and they’re stuck on something. And sometimes you have trouble figuring out where they’re stuck and you got to come up with a new way of explaining that makes sense to that individual learner. And so one of the benefits of teaching for a long time, you say, well, okay, that didn’t work. Let me try this other thing that sometimes works with students. And let me try this other thing and a demonstration or a drawing, or just another method of teaching. So there’s, there’s never something that’s perfect for everybody. And so I’m always looking for another way to get that light bulb to go on, you know, again, when you get that sense that, Oh my God, now I get it. There’s nothing better. I think, as a teacher, when that, when that individual student says, yep, I get that now. You know, you’ve really achieved something.

And I’ll bring up something that’s related to this that’s controversial today, I think at some level, which is that sometimes, and the term that’s often used is effortful learning – that struggling with a problem and then coming up with the answer on your own is much more powerful than my just giving the student the answer. And yet in this day and age, there is a sense that it’s, I don’t know, if it’s not comfortable for the student, if they feel like they’re struggling, then you’re not doing your job as a teacher. We have to minimize the stress, the anxiety, the whatever, you know, that goes on when learning is difficult. And yet it is much more powerful and so there are times when I tell the students, you know, I’m not giving you the answer. Now, I want you to go home and think about this. I may give you a hint. I may say, refer back to something we talked about three days ago because there’s some common principles there, but you need to work on this. And we’ll have something even in the intensive care unit when I’m taking care of patients and teaching at the same time, and a question will come up and we don’t need to answer the question that moment, to take care of the patient that moment. And I’ll say to the student or the intern, the resident, say, you know what? I want you to think about this and come back tomorrow morning on rounds, tell me what you came up with. And I know what the answer is, and I could have just told them quickly right then and there, that’s not going to be as powerful for them. They’re not going to remember that as well as if they come up with the answer on their own. And so there are times when I think a good teacher knows when not to give the answer and to let the students struggle a bit.

Michael Parker: Yeah. I a hundred percent agree. I mean, I’ve, you know, in terms of the struggle of learning, I’ve seen that in my own learning and say, and I think, you know, you go through a transition yourself as a learner, basically to understand that there’s actually a desirability to feeling like you’re struggling a little bit, because, you know, the knowledge will be more durable, more transferable, more useful later on. So it’s a, I think that is, that’s one of the learning processes about how you yourself learn.

Rich, I want to thank you so much for, for sitting down today as, as always, it’s really inspirational and instructive to, to hear all of your thoughts and just to see the dedication, you know, the dedication that you put into to educating people and how much you care about students and the thought you put into to changing your teaching over time and truly understanding how to, how to teach people well. So, so thank you so much for sitting down with me.


Richard Schwartzstein: Well, thank you, Michael, for the opportunity to share some of my experiences and some of my thoughts with your audience.


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