PE R S PE C T IV E
Why Is a Cow?
Why Is a Cow? Curiosity, Tweetorials, and the Return to Why
Anthony C. Breu, M.D.​​
I  recently had the following ex-
change with my 4-year-old
daughter while reading her favor-
ite book at bedtime:
Me: “.  .  .  with Emma Rose inside.”
Daughter: “Why was Emma Rose in
the house?”
Me: “Because she was sleeping.”
Daughter: “Why was she sleeping?”
Me: “Because it was nighttime.”
Daughter: “Why was it nighttime?”
Me: “Because the Earth rotates.”
Daughter: “Why does the Earth
­rotate?”
To this fourth “why,” I replied
“I don’t know” and moved on
with the story. After finishing the
book, I sat in bed wondering not
only about the potential answers
to my daughter’s question, but
also why I’d failed to ask it my-
self. Had I lost my curiosity?
When I was my daughter’s age,
I, too, asked series of “why” ques-
tions. And my parents did their
best to answer them, just as I do
now. My father had a more well-
developed closing technique: when
I arrived at a question for which
he had no answer, he’d respond,
“Why is a cow?” It was his an-
nouncement that we’d reached the
limit of our collective knowledge
and that the dialogue was over.
In the intervening years, al-
though “why” never fully remit-
ted in my consciousness, it was
overtaken by “what,” particularly
as I trained for a career in medi-
cine. What is the treatment for
community-acquired pneumonia?
What is the differential diagnosis
for upper gastrointestinal bleed-
ing? To succeed, I needed to mas-
ter “what.” “Why” remained large-
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ly latent. But though “what” has
served me well, its questions are
not as absorbing, and its answers
not as gratifying.
About a year ago, “why” recru-
desced when I recognized a gap
in my understanding of patho-
physiology. Whereas I knew what
happens when people have a mas-
sive acute hemorrhage (they be-
come anemic), I realized I did
not know why they became ane-
mic — though at this point I had
been a doctor for 12 years. The
explanation is fascinating, and
when I posted it on Twitter,1 I re-
alized that although even noncli-
nicians knew the answer to the
“what” question, most people had
remained comfortably ignorant re-
garding the “why,” just as I had.
Since I posted the answer, my
opening tweet has been seen by
more than 120,000 Twitter users,
and more than 10,000 of them
viewed the entire nine-tweet
thread. The size of that audience
far outstrips the reach of any pa-
per I’ve written or lecture I’ve de-
livered and signaled that I was
far from alone in being fascinated
by questions about pathophysiol-
ogy and mechanisms of disease.
The thread about anemia in
acute hemorrhage was my first
“tweetorial.” Tweetorials have been
defined in various ways, but in
medical education they are most
appropriately viewed as a collec-
tion of threaded tweets aimed at
teaching users who engage with
them. Tweetorials may include
polling questions so that viewers
can test themselves; pictures,
videos, and short animated illus-
Why Is a Cow?
trations that are especially help-
ful to visual learners; and links
to primary resources for addition-
al, self-directed learning. More-
over, with more than 126 million
daily users, Twitter offers a rich
medical community for peer re-
view, feedback, and discussion.
The platform allows students to
interact directly with professors,
temporarily flattening hierarchies
and opening channels for com-
munication that are unavailable in
conventional medical education
formats.
As educational tools, tweeto-
rials have been widely embraced.
Some experts use them to supple-
ment their lectures or podcasts or
to promote newly published re-
search. The uptake of those that
I have researched and posted is
probably attributable in part to
the persistence of human curios-
ity. Though many of us in medi-
cine do not lose our interest in
“why,” its easy replacement with
“what” is troubling. If used cor-
rectly, Twitter can be a haven for
physicians who hope to rekindle
and stimulate the curiosity that
made them choose a career in
medicine. The shift in focus is
what gnawed at me when my
daughter asked about the Earth’s
rotation: her question highlighted
the primacy of “what” in my per-
sonal and professional life and
the reality that I had become con-
ditioned to seeking facts, not ex-
planations.
My experience is not unique,
nor is the call for a return to
“why.” In 1999, Faith Fitzgerald
outlined the rewards of curiosity
1097
PERS PE C T IV E
but also noted that “it is our duty,
as those who now teach young
physicians, to identify medical
students with a gift for curiosity
and take infinite pains not to sup-
press but to encourage that gift.”2
In 2016, Simpkin and Schwartz­
stein urged educators to ask ques-
tions focusing on “how” and
“why,” not “what” as one way of
“encouraging students’ curiosity
to explore and capacity to sit
comfortably with uncertainty, ac-
knowledging that certainty is not
always the end goal.”3
Although the push for curios-
ity is not new, social media offer
new modes for its expression and
cultivation. Twitter, for instance,
showcases the tolerance of uncer-
tainty that Simpkin and Schwartz­
stein champion by fostering a
public conversation between an
emeritus professor and a medical
student over a shared love of ask-
ing questions.4 And if they need
help arriving at valid answers,
Twitter offers a vast network for
expert response and dialogue.
This community also provides
new opportunities for engage-
ment — including online chats
and journal clubs — that were
unavailable in the past.5 Though
social media sites are often seen
as homes of vitriol, I have found
1098
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Copyright © 2019 Massachusetts Medical Society. All rights reserved.
medical Twitter to be a venue for
advocacy, empowerment, and yes,
curiosity.
The emergence of tweetorials
inspired me to dive deeper into
the mechanism of anemia in acute
hemorrhage and then to share
what I’d learned. Just a year ear-
lier, I would have mentioned my
newfound understanding to a few
colleagues, then tucked it away
in the back of my mind. Now, I
and many others look for oppor-
tunities to turn curiosity into
tweetorials that are vehicles for
teaching. They’re a new and use-
ful tool for nonsynchronous edu-
cation, learning that fills the men-
tal space and time of the learner
instead of asking the learner to
fit within the space and time of
the teacher. Given that time and
mental energy are two of physi-
cians’ most precious commodi-
ties, this flexibility is crucial.
One hope is that tweetorials —
and Twitter more generally — al-
low physicians and trainees to
seize a few of the in-between
minutes, the time we spend wait-
ing for a meeting to begin or rid-
ing an elevator, and reclaim them
for the development of curious
inquiry. But we need even more
than time; with the rising rates
of burnout, we also need the
n engl j med 381;12 nejm.org  September 19, 2019
The New England Journal of Medicine
Why Is a Cow?
mental space and energy for en-
gagement. So my other hope is
that the excitement of the “why”
questions explored in tweetorials
will be as restorative for others
as it has been for me.
As for my daughter’s question,
the Earth rotates because of the
angular momentum that resulted
from asymmetrical gravitational
accretion after the Big Bang. And
if my daughter asks me “Why
was there a Big Bang?,” I’ll be
forced to reply, “Why is a cow?”
Disclosure forms provided by the author
are available at NEJM.org.
From the Veterans Affairs Boston Health-
care System, West Roxbury, MA; and Har-
vard Medical School, Boston.
1. Breu A. Why do patients with acute hemor-
rhage become anemic? Twitter (@tony_breu).
June 5, 2018. (https://twitter​.com/​tony_breu/​
status/​1004181592582119429).
2. Fitzgerald FT. Curiosity. Ann Intern Med
1999;​130:​70-2.
3. Simpkin AL, Schwartzstein RM. Tolerat-
ing uncertainty — the next medical revolu-
tion? N Engl J Med 2016;​375:​1713-5.
4. Centor R. Should we move to quantiferon
testing? Do we need isolation in the absence
of productive cough? Twitter (@medrants).
June 4, 2019 (https://twitter​.com/​medrants/​
status/​1135996832700620801).
5. Topf JM, Sparks MA, Phelan PJ, et al. The
evolution of the journal club: from Osler to
Twitter. Am J Kidney Dis 2017;​69:​827-36.
DOI: 10.1056/NEJMp1906790
Copyright © 2019 Massachusetts Medical Society.
Why Is a Cow?