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Focus on Thomas De Fer, MD FACP

Thomas De Fer, MD, FACP is an associate professor of medicine in the Division of Medical Education.

You are very involved in the residency program, do you also see patients?

I do, but the context in which I see patients is a little bit hard to understand. When I see patients, it is in a teaching and supervisory roll. Because I’m so involved in the residency program, that’s how I interact with the patients. Ultimately, every patient that’s seen on my watch is my responsibility.

What brought you to Washington University?

That was easy. I am an ‘almost’ native of St. Louis. We moved here in 1972 when my dad came to be the director of ROTC at Washington University. I went to the University of Missouri for college and medical school.

I was really glad to have the opportunity to do my residency at Washington University. I didn’t have any of the angst that a lot of people have when deciding where to go for their residency. For me it was a no-brainer -- I was coming home.
Dr. De Fer in Barcelona



Your specialty is internal medicine, how did you make the transition to medical education?

That’s an interesting story. When I was chief resident, there were a lot of educational duties that went with the job, and I enjoyed those very much. During that time, the clerkship site director went on maternity leave, and I took care of her responsibilities. When she returned to work, she told me to continue with what I was doing. It was a case of being in the right place at the right time.

After my chief residency year, I was also one of the first people involved in the hospitalist program at Barnes-Jewish Hospital. We made the business plan and put it into action. During this time, I realized how much I enjoyed teaching, interacting with the students and residents, and wanted to still be a part of it. So while involved in the hospitalist program, I continued teaching on a voluntary basis – I thought it was good for me and the university.

Another piece of good fortune came about for me when the division of general medicine was created within the department of medicine, and they asked me if I was interested. I said “absolutely, but I would need to bring my work with the residents and students”. I expected my job to be largely educational – which it was. I also took on another portion of internal medicine clerkship at that time.

I was terrifically lucky that the events came together the way they did – allowing me to end up with a job that fit my interests so well.

What is patient simulation?

One of our teaching tools involves simulating patient experiences. We prepare cases where a person acts as a standardized patient and the student acts as the doctor. The student takes a history and performs a physical; he or she then assesses what is wrong with the patient and what to do -- either diagnostically or therapeutically.

This kind of testing is very labor and cost intensive, but it works nicely for providing formative information for the students. For beginning clinicians, it’s really hard to take that step and say, ‘OK, if I were in charge, this is what I would do.’ That’s a big change, and the students get significant information from this interaction.

We do make it clear to the students that this is just a single snapshot into what it’s like to be an independent clinician. Based on this one test, they should not judge themselves either too fairly or too harshly.

Do the medical students get more than one opportunity for the standardized patient testing?

They do. We now have a program that stretches over all four years of medical school. So students have interactions in some way with a standardized patient during each year. At the end of fourth year they have an encounter where they see patients with six different problems -- this is an attempt to prepare them for one of the board exams that involves ten standardized patients.

If you have to have a license to drive, shouldn’t you have to show that you can follow the rules of the road when you are seeing patients? That’s really what this is. We want to make sure our students are prepared to interact on the level for that kind of high stakes exam. If they fail, it’s a big deal. They can’t move on until they’ve passed.

What do physicians in medical education do?

To be a good educator, it takes more than just being a talented teacher. Obviously that’s an important part of it. Everything starts with developing a curriculum, so an educator has to be able to think about the needs of the students, the school, and in our case, society as a whole, in terms of making good doctors.

We decide what to teach and then have to figure out the best way to achieve it. Is this experiential? Is it a group lecture? Is it a small group discussion? Is it a skills laboratory? Is it a standardized patient interaction? Is it a reflective writing piece? Whatever it is, we have to determine which methods to use to teach the students.

Our students, being adults at the highest level of achievement, have a great deal to say about how we impart the curriculum on them. But sometimes there are some reasons why we simply can’t execute an educational activity in the way the students think is ideal.

Another aspect of being a good educator is finding real ways to evaluate students. That’s one of the most difficult areas in medical education. It’s not so simple as to just give a test.

Have you found that the medical students come to you for guidance when they are choosing their specialty?

That’s one of the activities that I get a lot of enjoyment in – I’m not making the decision for them, I’m just helping them along in terms of figuring out what’s most important to them and how some careers might be able to fit that bill. I think students sometimes put individual specialties into boxes and think that there’s just no way that field would ever accommodate his or her unique wants and desires, when in fact that may not be true at all.

Guiding the students gives me the opportunity to help someone feel better about making decisions -- which is pretty ironic coming from a person who doesn’t make personal decisions very easily.

It’s also important to have a backup plan when choosing what comes next for your education. Don’t assume that if it doesn’t work out as hoped, the world has come to an end. When in fact, what you achieved what was right for you.

Where are you from?

My family is originally from Detroit. My father was a career army officer so we travelled quite a bit. We lived in West Germany for my first three years – which frankly I don’t remember a thing about. My older brothers have all kinds of fond memories of West Germany – and unfortunately I don’t. My siblings were born at Ft. Leonard Wood – a large army base in Missouri. Right before we came to St. Louis, we lived in Oklahoma – which is a great place to be a kid – tornados and wicked thunderstorms. Then we moved to St. Louis and I’ve pretty much been here since – except going away to college and medical school. I’m really quite content to be a Midwestern boy. It’s really easy to live here.

What do you like to do in your spare time?

If somebody asks me how I define myself outside of being a doctor and a teacher, the very easy answer is I’m a gardener. That’s really my passion for many months of the year. I hope when people come into my backyard that they can see my personality. I spend excessive amounts of time trying to make it as perfect as I possibly can. I take even the small defeats very personally
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My other passion is my dogs -- I have four. They each have an individual, sweet personality, but they can still get into serious trouble. One of my dogs likes to eat hostas. I thought I had completely cured him of that behavior – until he recently ripped apart one of my favorite, biggest hostas – I was just beside myself.
Fountain in Dr. De Fer's shade garden


Is there a particular award or achievement that is most gratifying?

There were two that mean a lot to me. The Founder’s Day Distinguished Faculty Award was very special. I was overwhelmed by the whole experience, it was amazing. I like to think that I’m good at what I do, but it was really special to have that recognition.

I also received an achievement award from the Clerkship Director’s in Internal Medicine. It meant a great deal to be recognized by the other clerkship directors for the work I have done.

What is the best advice you have ever received?

Find a niche and fill it. Do it the best that you possibly can and if you do it that way, you will always be valuable.

If you weren’t a doctor, what would you like to be doing?

If I weren’t a doctor, I would absolutely love to be a gardener for other people. They can pay for the plants and I would plant them -- but I would be jealous if their garden came out better looking than my own.

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