Rethinking Medical Education

The ThinkerQuestions, observations, and recommendations toward reform of the process and content


Medical school curriculum - Part 1:
We must do better than we’re now doing*
The educated usually find themselves equipped 
to live in a world that no longer exists.
Eric Hoffer 
(US writer on social issues; 1902–1983)
Sixty years ago, when I was becoming a physician, medical school curricula were highly rigid, especially in the “basic science” years. At least in the US, they were also strikingly similar from school to school. In one of my early comments on curriculum design during that era I asserted that a randomly selected medical student in a randomly selected US medical school could probably be transported to another randomly selected school and continue his studies (then, nearly all US medical students were male), hardly noticing any changes in the expectations and tasks, and probably not finding much variation from the dull lecturing that dominated his time at his first school.
Curricular variations are here and growing. The current situation is meaningfully different from even 20 years ago. Instead of severely constraining curricular innovations, as they once did, accreditation groups and other influential leaders in medical education are being flexible. They are permitting, even encouraging, (some) deviations from the standard programs of the past. But, many signs of the past, and constraining influences remain. In general, established faculty members are inclined to sustain what is familiar from their own past, so medical schools tend to offer relatively minor variations from long-established curricular patterns. Sadly, for example, there is still widespread perpetuation of the separation of basic sciences education from clinical care, which is traceable to a misunderstanding of the message of the highly influential 1910 “Flexner Report.” In 1924, in a follow-up commentary, Abraham Flexner himself bemoaned that disappointing situation.
 During recent decades, many of the newly emerging medical schools, and a few well-established ones, have introduced some worthy and interesting variations in their curricula. Still, within each individual curriculum, regardless of how different their structures may be from most other curricula, there is still, usually, less flexibility than is needed for optimal learning by all students, and other legacy flaws continue to be perpetuated.
Many serious flaws from the past remain
In addition to the artificial and hurtful separation of basic science learning from clinical experiences, we have many leftover approaches that are still being corrected too slowly, if at all, in many of our world’s medical schools. Some of the most serious flaws (practices that violate the evidence of how humans learn best, as identified by good educational and brain science) are:
  1. We assume we know what all learners will need before we know much, if anything, about them as individuals: their readiness for the various aspects of medical learning, their current capacities, their actual needs, and more.
  2. We standardize the experiences we offer, ignoring the enormous diversity among learners.
  3. We move students from discipline to discipline, often hour-by-hour, providing no time for reflection, discussion, practice, or other steps needed for consolidating their learning.
  4. In our teaching and testing we continue to expect large amounts of memorization, despite the many limitations of human memory, the wide availability of memory-support technology, and the likelihood that much of what we expect students to remember will be irrelevant to the careers of many, if not all of them.
  5. We give high emphasis to the acquisition of information, despite the likelihood that much of that information will be obsolete relatively soon.
  6. We give insufficient emphasis to cognitive skills, such as information searching and assessment, problem analysis, and complexity management.
  7. We largely neglect social and emotional competencies, despite their central importance for intimate, human-oriented work, such as healthcare and teaching.
  8. We postpone or deny students opportunities to be doing for themselves the cognitive, emotional, and performance tasks they need to learn. Instead, we keep them passive for long stretches of time, merely reading about, or hearing about, or observing others doing those tasks.
  9. We postpone our assessments and the limited feedback we provide until far too late for having a constructive influence on learning.
  10. We do little, if anything, to ensure that those selected to teach are actually competent as teachers and are prepared for this important, challenging, complex professional work.
Curricular structures are changing; rigidity remains
The design and operation of many curricula have been contrary to, rather than supportive of, meaningful learning. The evidence is strong that our approach of providing largely similar experiences in medical school for a group of people who are highly diverse, who come from a wide variety of educational backgrounds, life experiences, and cultural traditions, and who have unique brain characteristics, is manifestly inappropriate. 
Even with the growing variety of curricular plans among our world's medical schools, within large parts of many curricula, groups of students are still typically expected to focus on the same topics, at the same time, in the same sequence, for the same duration, and are examined in the same ways. Not surprisingly, medical students, too often, consider medical school an initiation process, a painful rite-of-passage, not a meaningful, engaging, valued set of first steps in their professional careers. They see their careers as beginning later, which, regrettably, leaves them with an insufficient sense of "ownership" of much of what they are expected to do and learn while in medical school. Without a feeling of ownership, learners typically perform below their capacities and derive less from their invested time and effort than they would if they felt authentically engaged in, and had deep positive regard for, their learning experiences.
An alternative way of thinking about curriculum
A reasonable analogy for thinking about curriculum, and how it should be formulated, is our approach to patient care. We take it for granted that patients are sufficiently distinctive, even unique, in their characteristics and in the expression of the condition that brings them to a healthcare facility, that the first step in caring for them is an appropriately targeted, often thorough, diagnostic workup. And diagnostic checks of their evolving conditions, including their responses to our interventions, are routine and individualized.
As clinicians, we devise unique outcome goals for each patient. The clinical care we provide for people if shaped by the individualized set of outcome goals we devise for each person. We adapt our expectations to an interplay among what is biologically possible, what our resources can provide, and what the individual patient's age and prior health circumstances indicate are reasonable expectations. In other words, although there are many commonalities among the recommendations and steps we offer different patients with similar conditions, each patient gets, and certainly should get, a uniquely crafted, often fine-tuned set of offerings. And those offerings are continuously adjusted, as needed, in response to the additional information we continue gathering about them and their condition.
As clinicians, we have a deep respect for human diversity. That respect is now well embedded in modern healthcare culture. I’m persuaded that this perspective provides an appropriate starting point for thinking about medical curriculum. Contemporary brain research is providing convincing evidence that we are even more diverse as learners than we are as patients. 
Educational programs should be highly individualized. They should be at least as individualized and as carefully customized as is our approach in healthcare. Like the healthcare process, the education process is a set of interventions. In healthcare, perhaps without noticing anymore, we carry with us a general understanding of the features of optimal health, which becomes our starting point for formulating the unique set of outcome goals we devise for the care we provide for each patient. We quickly, often automatically, adapt our expected outcomes to the realities of each individual patient's situation.
Toward outcome goals for medical education
Although we aren’t likely to soon reach the same level of agreement about an idealized set of outcome goals for medical education as we have for healthcare, I propose that we need to work toward a far clearer sense of those desired outcomes than we now have. And, as we do in patient care, we need to then move backward from the ideal toward a formulation of individualized goals for each student, appropriately adapted to that person’s unique set of characteristics and needs. As we also do in patient care, we must postpone our formulation of goals for each student until we've assembled an appropriately thorough array of diagnostic findings for that person. 
The goals we formulate for each student must be developed in collaboration with the student, and must be seen as dynamic. These outcome goals need to be subject to continuous revision, guided by new findings that emerge from our continuing diagnostic data-gathering over time. Our long-standing heritage ofassuming we know what all students will need, even before we've met them, is badly overdue for rejection and replacement with a more appropriate approach, as I discuss further in Part 2.

   Hill Jason
Hilliard Jason, MD, EdD
First posted: 1/24/12
Revised: 1/25/12
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* NOTE-1: As with all entries in this blog, your constructive critiques, recommendations and reflections are warmly encouraged. Please add your Comments below, or, to convey your reactions privately,  please send an email to: hkj337@gmail.com. Many thanks.
* NOTE-2: I’m currently part of a small group that is conceptualizing a possible new kind of medical school for Europe, so, many elements of educational design are very much on my mind at this time. Inescapably, curriculum is a central consideration. My reflections for our deliberations have helped spawn this and other blog postings.

2 comments

  1. IronmanAndrew  

    Zen and the art of Motorcycle Maintenance is always my go to resource when trying to rethink my processes for education. Great post thanks for the info!

  2. Rahul Patidar  

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