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A Critique of Fashion in Medical Education
Some thoughts on the report of the Panel on the General Professional Education of the Physician and College Preparation for Medicine
(To see a comment regarding this article go to the 22nd June 2014 blog)
Reprinted from NEW YORK STATE JOURNAL OF MEDICINE, Vol. 86, August 1986: From a lecture given June 14, 1985 at a symposium on “Medical Education in the 21st Century” held at the Bowman Gray School of Medicine. Wake Forest University, Winston-Salem, NC.
Fashion
though folly’s child
and the guide of fools,
rules even the wisest
and in learning, rules.
George Crabbe, 1754-1832
These lines by Crabbe, the East Anglian poet/surgeon/cleric, written about 200 years ago, express well how fashion can dominate the thinking of even the wisest people and is paramount in educational matters. However, though it is easy to complain about the influence of fashion on education, it’s not so easy to do much about it in practice. In something as complicated as medical education, where it is virtually impossible to prove or disprove a hypothesis with certainty, arguments may do little but illustrate the prejudices of those taking part. This may explain the reticence of the wiser among us in not adding to the noise levels in such debates. Their most eloquent comment may be their silence. Perhaps I will grow wiser one day and keep my mouth shut but I have been so disturbed and angered by the cynicism and the damage to academic standards and morale that often follow the introduction of half-baked educational systems into our medical schools that I am grateful for being allowed to air some of my prejudices on the subject. I know virtually nothing about educational theory; my thoughts and feelings on medical education come from some 40 years of teaching and being taught in universities in different parts of the world.
In my lifetime I have seen so many fashionable theories wither in the light of experience that my faith in theories as a guide to truth is slim. Experience has shown that most simple theories, whether they deal with economics, politics, education, or whatever, no matter how logical, fashionable, or attractive they sound at the time, usually do not work well when tried out in real life situations. If this means that we must muddle through with pragmatism and what I like to think is common sense, so be it.
Nothing beats experience for evaluating theories. My father was a clergyman. When he was a young minister he gave a talk that was popular at meetings of young mothers in his parishes. He called it, “The ten cardinal points for bringing up children.” Then he married and had four normal, healthy children, of which I was the third. The ten points soon fell to seven. When it reached three he abandoned the talk. A generation later, the enlightened theories of Dr Spock provided my wife and me with the up-to-date, modern model we hoped would result in problem-free, happy, and fulfilled children. Now that our children have grown up, I wonder, could this be where we went wrong?
When I was young I was an expert on America. I had watched so many American movies that I felt entitled to pontificate on all things American. In 1960, however, the Harkness Foundation gave me a fellowship to work and travel here. A condition of the fellowship was that, in addition to spending a year or so working in a university, I should spend several months not visiting universities, but exploring the country, meeting people and just going wherever I wished. They provided me with a rented car to do it. Though this seemed self-indulgent and rather offended my work ethic at the time, the four months spent with my wife and baby daughter touring America and meeting Americans were amongst the most memorable and instructive in my life. Never again could I generalize about the characteristics of this great conglomerate of nations, attitudes, life-styles, terrains, and climates. America (and medical education for that matter) does not lend itself to such over-simplifications. The only common thread throughout our journey was the great kindness and hospitality shown to us in all parts of the country.
As an eager young academic, I knew exactly what was wrong with medical education. When I was made chairman of my department I had an early opportunity to correct matters by trying out the newer educational theories on our students that for some strange reason my predecessors had seemingly ignored. To my great disappointment, their implementation often made little difference to the students’ happiness or level of achievement, but caused them some anxiety and the department considerable extra work and expense. We tried to salvage the best of each new system and graft it onto the old, but mostly it might have been better to concentrate on improving the old system and avoid the disruption that the change in curriculum caused.
It is against this background of lost innocence that I react so negatively to people who complain stridently that traditional medical education is virtually useless, if not harmful, and that if we would only implement the latest new educational theories, it would make it all better. Especially so when it is said in a pompous way with near evangelical zeal on equivocal evidence. Life just isn’t as simple as that. I go along with Malcolm Frazer, the ex-prime minister of Australia, who said, “Life wasn’t meant to be easy.” I hope I will not be thought too complacent for my opinion that the traditional medical curriculum provides one of the most interesting and absorbing courses available in a university. It is not perfect nor would I expect it ever to be so. Nevertheless, I would treat it with respect and not tamper with it lightly since its evolution has drawn on some of the best minds and highest ideals in human history.
Some of my early and arrogant efforts to improve our own curriculum were as counter-productive and vandalistic as my effort to improve the appearance of a Victorian brass bed by sawing off its elegant but extravagant superstructure. I am not sorry that the inertia in most medical schools protects them from the worst excesses of educational vandals; that degree of protection is needed today more than ever.
Of course I would not want to prevent change and could not prevent it even if I did. New people and new ideas will always keep our curriculum on the move and it has to adapt to changing times and conditions. That is why it is as good as it is. But I would worry if the rate of change were so great that there was not the time to evaluate the merit or otherwise of the changes introduced or if it resulted in irretrievable loss of some of our traditional strengths.
Perhaps then you will bear with me if I discuss some of the recommendations in the GPEP Report, also known as Physicians for the Twenty-First Century, since I feel they incorporate some of the fashion of our time. It would be surprising of course if they did not. Though spelt out at some length in the report, they can be summarized briefly. In general they deal with matters of emphasis rather than matters of absolutes. On student selection, it is recommended that medical students should have a broader educational and social background and be selected on personal characteristics rather than just academic performance. On curriculum content, it is recommended that emphasis should be put on principles rather than facts; attitudes and skills as much as knowledge; the medicine of the future as much as the medicine of the past; and the medicine of the community as much as the medicine of the specialist hospital. On curriculum organization, the report recommends that medical education should be faculty rather than department-based; integrated rather than subject-based; and active rather than passive. With regard to student assessment, it recommends that evaluation should be subjective rather than objective and continuous rather than periodic. It also recommends drawing up clear educational objectives, fostering literacy, and, perhaps predictably, spending more public money on medical education.
Now these sound quite logical and, when younger, I might have accepted them more easily. However, now that I am older I have reservations about them as panaceas for medical education. Just because a thing sounds logical does not mean it will work. Indeed I worry that revolutionary adoption of some of the ideas in an extreme form might weaken the morale and traditional strengths of our schools.
STUDENT SELECTION
Selection from a Broader Educational and Social Base
It is fashionable to suggest that the medical students we now select have not a sufficient breadth of education. I would be surprised if they ever had! However, to overcome this the report suggests that premedical education should cover not just the natural sciences but the social sciences and the humanities as well. Off the cuff, I suspect that most of us would side with the angels and plump for a broad rather than a narrow education. But on reflection it is not that simple. A study in the breadth suggested could make exposure to each area so superficial that its educational value would be worthless. To produce a good musician, you do not attempt to teach him every instrument. Similarly, you will not produce a good scholar just by exposing him to a little of everything.
I understand the thinking behind the recommendation, however. There is worry that the college efforts of intending medical students are geared excessively to excelling in physics, chemistry and biology to the exclusion of other subjects. Personally, I do not worry too much about that. The best way to learn about learning is to study in depth and it is not impossible to teach the liberal arts through the sciences. Biology, for example, has a history, a geography, a literature, many languages, a mathematics, and a philosophy – not to mention social and ethical implications. There is no reason why a good biologist need be narrow intellectually. For educating the mind, the rapport built between teacher and student may be more important than the subject taught. Exposure to many teachers in short courses covering most of the disciplines taught within a university is no guarantee of a good education if no teacher has time to make much impact.
In advising medical schools not to make entrance requirements too restrictive, the report questions whether medical students need a scientific background to benefit from the course. Many newer schools believe they do not, and may be correct provided the students are bright and motivated. However, I suspect that lack of a science vocabulary must be a handicap for the average student in coping with the average medical course and I advise intending medical students accordingly.
It is popular to argue that students from disadvantaged minority groups should be selected to provide an appropriate mix of medical manpower and to correct social inequalities. The report puts it this way: “Continuing effort is needed to increase the opportunities for under-represented minority students to be prepared for medicine in college and matriculated in medical school.” I accept that, but feel that medical schools should not compromise their standards, courses, or procedures to do so. I see medical schools as places providing medical education of an acceptable standard to all students qualified to benefit from it. I do not see them as instruments for social engineering and my experience suggests that those who do, pay heavily for it in educational and human terms.
Selection on Personal as Much as on Academic Qualities
There is a theory that the medical students we select may be too single-minded and too clever to be good doctors and that they do not possess the human qualities and independent learning skills that future doctors will require. My trouble here is my uncertainty about identifying, let alone measuring, the personal characteristics required to be a good doctor. Like everyone else I have my prejudices on what they are but, unless I’ve known someone for years, I cannot be certain they possess them. Even if a psychologist assures me that they do, how can I be certain they will retain them in later life? Personal characteristics are easily simulated. I have been saddened by the mental dishonesty adopted by some candidates as they simulate the attitudes they believe are needed for selection. Inwardly I sometimes cringe when I read those awful essays written by otherwise bright and honest students on why they want to become a doctor; how they had this sudden call as a child to heal the sick and splinted their teddy bears’ broken legs. Any system that encourages pretence and mental dishonesty is a poor screen for medicine.
I am happier to base selection on objective measures of academic performance. I do not believe there is an inverse relationship between academic skill and humane values. If students do well academically, they must be reasonably bright, reasonably determined, and have reasonable mental and physical health. Can we ask for more? Within the diversity permitted by such objective selection should be most of the qualities that doctors might need in the future.
What worries me even more is the tendency of some of the newer medical schools to recruit staff on the basis of their beliefs and personal characteristics rather than their academic performance. If it is decided to start a new medical school with a particular new philosophy that emphasizes certain personal characteristics, a dean will be found who espouses that philosophy. To prevent the philosophy being subverted, foundation staff is recruited that shares or pretends to share those beliefs. An emotional commitment to the belief or philosophy then becomes more important than academic merit when appointments are made. Anyone who criticizes the school credo risks being branded a dangerous heretic or disloyal to the pack. To some extent it’s like joining a monastery; one must subscribe to the institutional beliefs to belong. The only real way to question the belief is to resign. I would prefer to work in an institution that will tolerate all varieties of belief and where the only credentials for membership are academic ability and integrity.
CURRICULUM CONTENT
“Emphasis on Principles Rather Than Facts”
There is a widespread belief that students spend too much time memorizing facts and that we should reduce scheduled teaching time and the amount of material we expect them to learn. Superficially this is attractive but it worries me for the following reason. I do not think we can understand anything well unless we first take the trouble to immerse ourselves in the facts. Initially, they may seem confusing and disconnected and the subject as a whole may not make sense. Though this is a depressing phase, it is important to learn to press on. If we keep grinding on, the pertinent facts drop into place eventually, and the subject as a whole begins to hang together. Concepts emerge. It is a very rewarding and exciting intellectual experience, when, as we say, the penny drops. The length of the latent period between beginning to study a subject and beginning to understand it varies, but in my experience is rarely less than six months.
I have tried repeatedly to discover ways of helping students contract or even bypass this latent period; it would so accelerate their education. But I have never been successful. To know a subject, it seems one must first put the facts that underlie it into one’s head. Using other stores such as floppy discs or library files is no substitute for mental assimilation. And, of course, our heads, especially when they are young, are superb at this, considering the vast amount of new information poured into them every day. What’s wrong with memorizing material? We all do it. When examining a patient one should go through an orderly series of drill-like procedures which have been memorized with precision; if one is to be thorough (let alone make a diagnosis), one shouldn’t work out the conduct of each physical examination by going back to first principles each time. People say, why memorize facts when one can look them up in a textbook or on a video display screen? That is as foolish as saying, why memorize words when they can be looked up in a dictionary? It would be virtually impossible to think or speak if one had to look up every word. Similarly, one can do little in medicine (or anything else for that matter) without a large store of working information in one’s brain.
Facts are the only constant reality (though some are more useful than others). Concepts and principles are necessary but they are merely theories to relate a set of facts and are usually ephemeral. Though concepts may seem more exciting than facts, they are no stronger than their factual basis. Take the analogy of the results and discussion sections in a scientific paper. The results section should give the unadorned findings or facts in a disciplined way that should be as true in 100 years’ time as it is today. In the discussion section one can hypothesize and elaborate concepts to relate the facts to the heart’s content. But, one can and must abandon these concepts when new facts emerge that don’t fit. A person whose knowledge is of concepts only, lacks the database from which to question the concepts and, if necessary, develop new ones. David Lagunoff, in a recent letter to the Journal of Medical Education, could not have put it better. He wrote:
“Medical students need facts; they need a well-developed medical vocabulary and an orderly conceptual framework to create the intellectual context in which reasoning and problem solving become possible. The most astute reasoning is quite useless if it is not carried out in the context of facts.”
“The Information Explosion”
It is fashionable to talk of the “information explosion,” that suggests that knowledge and the amount we require our students to memorize is increasing exponentially. This sounds reasonable but it is not quite like that. I had a great-great-uncle who was one of the first students at our medical school in Belfast about 130 years ago. He was awarded a book prize in physiology on the results of a first year examination in chemistry in 1858. It is a splendid, heavy, leather-bound book which I admired greatly as a child. I can remember thinking how clever doctors must be to know so much. Later, after I read physiology, I began to wonder how so much text could be written at a time when so little was known about physiology. Would, for example, this great tome say nothing about the adrenal cortex on the grounds that nothing of its function was known? Not so – the section on the adrenals was longer than in most modern student texts; it described in detail the structure, blood supply, nerve supply, comparative embryology, and comparative anatomy, hypothesized about this and that, and built up the concept that it might add “nutrients” to the blood. The number of facts to be memorized by the student then was as great as, if not greater, than it is now; the difference today is that a more pertinent set of facts is presented to the student to allow him to see the present-day concept.
In another 130 years I suspect that we will not present the student with more facts about the adrenals, merely more relevant facts to give him the concept of the gland that is fashionable then. This brings us again to the crucial importance of good teaching. From the countless facts available of varying relevance, a teacher must guide students towards those which permit the formation of concepts and if necessary their modification in the light of new knowledge. The teacher does not do the students’ work for them, merely points them with the appropriate facts in the right direction.
“Information Technology”
In all branches of learning today, and medicine is no exception, it is fashionable to argue for better “IT”; in other words, “information technology,” to deal with the “information explosion,” and that students should have instruction in its use. To me, there is little fundamental difference between storing information on floppy disks, notebooks, or card indexes and I would give training in the use of computers no more or no less emphasis than I would give to training in keeping good records or in the use of libraries. All seem useful technologies that can facilitate our work. The important thing, it seems to me, is to limit the time wasted by students learning ephemeral skills. I find that as soon as I learn one way of communicating with a computer, they change the language (if not the computer). At one time, people convinced me I should learn the electronics on which medical technology depended. So I spent many happy but rather useless hours constructing a radio from resistors, capacitors, etc. But I was weak on electronics; my radio crackled quite a lot (perhaps because of cold solder joints), and soon my fledgling skills were made obsolete by the introduction of printed circuits. I suspect that doctors should not divert too much time to rediscovering the electronic or computer wheel but should use electronic and computer experts to provide the services they need.
“Emphasis on Acquiring Attitudes and Skills as Much as Knowledge”
The theory here is that having the proper attitudes, values, and learning skills may be more important than knowledge to doctors of the future and should be stressed accordingly. What about teaching attitudes? Attitudes are important but are difficult to teach systematically without evoking cynicism. You may know of the disadvantaged boy who, when asked to write an essay on police, wrote, “Police is bastards.” His teacher, worried by this negative social attitude, took him to a kindly police sergeant who explained at length the social role of the police in protecting the weak, helping the young, and so on. In his next essay on police, the boy’s teacher was depressed to see little improvement; all he had written was “Police is cunning bastards.”
I suppose the only way to teach attitudes and values is by example. Medical students are as perceptive as the youth at the police station, and if they detect a difference between what people say and what they do regarding attitudes and values, they become cynical and their cynicism is justified. It comes back to the crucial factor in education, the quality of the teachers. If the attitudes and values they exhibit through their work are what we would wish, we do not need formal teaching to inculcate them.
Can we teach skills? We can teach people how to do things. I am not sure we have time to make medical students very skilful at anything. For me personally, skill only comes when I have done the same thing over and over and over again until I am almost sick of it. A person can be taught to row in an afternoon; it takes years to make an oarsman. So I do not worry much if medical students leave me with only rudimentary skills. They have their whole professional lives to perfect the skills I would like them to have if they are to practice on me in my old age.
It might be good educational practice to teach each student to develop one skill to a high level. This might show that nothing is very easy and that to do anything really well needs hours and hours of practice. Learning this lesson could be important for people whose appreciation of skill may determine what they do, or more importantly don’t do, to their patients.
“Emphasis on Teaching the Medicine of the Future Rather Than the Medicine of the Past”
The theory underlying this recommendation in the report is that since our students must work in the future, there in little point in teaching them the medicine of the past. It is hard to object to this since students who work in the future will find that the incidence of disease and the way it is treated change continually. It raises the important issue, pertinent to all education, of how to train people for work in the future. It is very hard to teach a satisfying course on material where we know virtually nothing. The future falls into this category and it is difficult to teach about it in a meaningful way. I suspect the only useful way to help people cope with the future is to illuminate the past. The past is all we can speak about with authority. If, by doing this, we can show that medical knowledge was seldom static but kept evolving as new techniques gave new opportunities; that problems arose continually and were often overcome; that new ideas kept bubbling up but virtually all proved useless, we can explain where we are today and how we got here. Then we can leave it to the young themselves to carry medicine forward. If they watch us adapt to today’s situations and uncertainties, when we fail as well as when we succeed, and see how we draw on lessons learnt from the past, they will learn the tricks and attitudes needed to deal with the unknowns of the future.
Teaching through research is particularly useful here since it gives insight into the thinking needed to solve problems. Here is another reason, if one were necessary, for having the best possible teachers – people for whom solving problems through research and adapting to new situations is second nature; whose attitudes will be as appropriate for work in the future as they were in the past, with a feeling for excellence, hard work, common sense, clear thinking, and above all, intellectual honesty. If such teachers can by their example pass on to their students the ability to think with honesty and simplicity, we needn’t worry too much for the future.
It is often said that the medicine of the future will have more to do with health education and preventing disease than with curing disease and that our courses should stress this. This is not a new idea and most of us would support it. I wonder why courses in health education and the prevention of disease are not more successful and popular. Perhaps they don’t fit so easily into the Hippocratic tradition of a one-to-one relationship between doctor and patient. I don’t see overt resistance in medical schools to teaching health education; I suspect it is just a difficult course to teach well.
“Emphasis on Teaching Community Medicine as Much as Hospital Medicine”
Since most encounters between doctors and patients do not result in attendance at hospital, the report advises that medical education should concentrate on medical work in community settings. This is sound advice yet hard to execute in practice. It is so much easier to monitor standards of medical care in hospitals than in community settings. There is little merit teaching in situations where standards of medical practice are not inspected and approved by faculty. To work well, the staff in community-based medicine and the courses they run must be no less exacting in their standards than those in the hospital-based specialties, and I suspect that it will take time to get it right if only because of the considerable logistic, financial, and other problems. Nevertheless, this is an area where there has been enormous improvement during my academic lifetime. The setting up of university departments of family medicine (general practice), geriatric medicine, mental health, and so on and the appointment to them of staff of first rate ability has transformed the perception of these branches of medicine in the eyes of our students (and perhaps in the eyes of some of our more conservative staff).
CURRICULUM STYLE AND ORGANIZATION
“Medical Education Should Be Faculty-based rather than Department-based”
The report reflects the widespread feeling that many departments are not really interested in teaching and teach all the wrong things in too great detail (especially pre-clinical departments). Most of us could think of examples to support this. However, it is sad when departments lose responsibility for their teaching since experts in a discipline should know best what contribution their subject can make to the medical course as a whole. Departments should know of the weaknesses and strengths of their own teachers and field these to the best advantage. Departmental teaching should permit better integration since one departmental member should know what the others are meant to be talking about and so reduce overlap or omission. When departments organize teaching it should be easier to provide cover for teachers who are ill or on leave. I like to see departments compete with one another to show their subjects in a good light, even if their motivation is only to encourage students to come back to work there later. I like to see them kept on their toes.
Taking responsibility for teaching away from departments is likely to diminish their interest in teaching. Their role in training their own staff in teaching skills is undermined. The groups within faculty who take over responsibility for the organization of the teaching program may not consist of the most prestigious or influential people in the school and this may damage the school’s perception of teaching. This, I think, is the crux of the problem. I would like to think that all faculty members should carry some obligation to help plan and deliver student teaching. I do not like to see this important duty left to a small caucus of self-selecting education specialists within faculty.
“Medical Education Should Be Integrated Rather Than Subject-based”
Though integrated teaching is widely perceived to be a “good thing,” and the report comes down on its side, there is often a yawning gap between theory and reality. Almost everyone pays lip service to it yet most people in my experience (except those responsible for it) are not entirely happy with it. I suspect it can be done well if one has enough time, enthusiasm, and resources, but it is not easy. Integrated teaching can be extremely time-consuming for the organizers and the teachers (they spend a lot of time in committees) and confusing for the students who have to grapple simultaneously with the different intellectual approaches of a variety of people in different disciplines, and it is bad for departments by removing their responsibility for teaching. Managerially, an integrated curriculum is a complicated curriculum and can result in bureaucratic inflexibility. The philosophy and scientific basis of an individual subject cannot be developed well in an integrated setting, nor is there time to develop historical themes which to me are very important in education.
Staging integrated topic teaching requires enormous managerial skill: marshalling troops, conducting briefing and debriefing sessions, making sure speakers do not contradict one another too much or overrun their times. Even then, the student may only get a series of disconnected mini-lectures lacking a cohesive intellectual theme. The presentations may overlap in content if the presenters do not know which of their points will be made by others. When everyone has spoken and the final panel discussion draws to an end, the show may have outlasted the willingness of the audience to listen. We always hope that next year will be better, but fate may frustrate us if the curriculum committee changes the topic or the organizer goes on leave. It is not for the faint-hearted.
Though subject-based teaching can distort proper balance, integrated teaching has much greater capacity for distortion. For most topics, certain disciplines have much greater relevance than others and to give them equal emphasis may not be helpful. To the outsider, neuro-anatomy and neuro-physiology seem obvious candidates for integrated presentation, yet the educational case for doing so is not convincing. Neuro-anatomists and neuro-physiologists can take completely different intellectual approaches to their subjects and to juxtapose the presentations can confuse the student. Neuro-anatomists may see the brain as a structure of beautiful and incredible complexity and describe it as such. The neuro-physiologist might prefer to see it as a black box and find the shapes so loved by the anatomist a confusing distraction.
In the end, each student will have to integrate the knowledge he gathers from many sources in a way that makes sense to and satisfies him. What better integrator could he have for this than his own well-trained brain. If he becomes adept in using it, he will find it a very useful tool to cope with the confusion and anarchy of the real world.
“Medical Education Should Be “Active” Rather Than “Passive”
The report stresses that medical knowledge is changing so quickly that a student who cannot learn independently will not be able to keep up after he leaves university, unless he has learnt to learn by active rather than passive means.
My problem with the active/passive concept is that the only learning I know of is the active variety. If there were a technique for “passive” learning which put material into my head at no personal effort, I should use it all the time. It is an effort for me to learn anything and I am grateful for any assistance. For this I will use all the “teaching aids” available, be they books, lectures, diagrams, video-cassettes, or, best of all, people who really know what they are talking about. These people are the rarest and best teaching aids and are in heavy demand. It is best if you can have a one-to-one relationship with them but, since there aren’t many to go around, it may be necessary for us to form groups to listen to them (say at a lecture) or else read their books or other publications individually.
Though these rare people were crucial in helping me to learn in what some might call a passive way, it did not feel passive at the time. My poor brain is easily confused and I had to keep thinking very hard about what I was being told, writing it out and asking questions before I could really come to grips with the material. So I am grateful to people willing to give time for lectures, talks, and writing to assist my learning process. If they were my teachers, I would be sad if they reduced the amount of scheduled time they were prepared to give to help me learn. I need all the help I can get. Left to my own devices without people to explain things to me, I don’t think I would have got very far, nor perhaps would any isolated member of the human race.
Tosteson (1979) made an important point that fits with my experience. He said that people, when asked about the most significant event in their education, usually did not mention a particular course, subject, book, place, or idea. No, in nearly every case they mentioned a person. It is people, not video-cassettes that really influence our mental development. A word – and an honoured word – for such people is “Teacher,” and they are the most important ingredient in the whole educational exercise. I do not think we should feel ashamed of wanting to influence our students through teaching. To prevent students being helped by good teachers seems nonsense and contrary to all human history. Independent learning, whatever that may be, can only be a pale and lonely substitute for learning from good teachers who have spent their lives working at and adding to the subject they love.
I cannot see that good teaching would limit a student’s ability to learn independently in the future and make him mentally lazy. I suspect that it can only increase intellectual curiosity and vitality, which one hopes may be passed on to others. Conversely, in my experience even the most sophisticated and enlightened teaching programs are worse than useless if they are taught or administered by apathetic or disinterested teachers who do not know or love their subject well.
STUDENT ASSESSMENT
“Evaluation Should Be Subjective as Much as Objective”
The urge to switch from objective examinations to subjective evaluation of performance comes from the theory that most examinations test only memorized information and not learning skills. Personally I do not follow this since I suspect that you need to develop learning skills even if only to memorize information. The report states that “standardized examination cannot replace reasoned analytical personal evaluations of the specific skills and overall abilities of the student.” I suspect the person who wrote that hadn’t much experience of grading large groups of students. Grading a person by what he looks like, says, and does is as fraught with difficulty as attempting to select students by the same method. I have not found it very reliable as judged by the different responses a single student can evoke in different members of staff. I suspect that students, who have a strong feeling for fairness, would want the criteria that determine progress to be reasonably objective. If I were an outsider inspecting a medical school, I would put more weight on an independent objective assessment using objective criteria than on any number of in-house self-evaluations.
“Evaluation Should Be Continuous Rather Than Periodic”.
Some people feel it is unfair to subject students to the emotional stress of important end-of-course examinations in which their progress will be determined based on their ability to reproduce samples of their knowledge. Some consider it kinder to evaluate students by continuous subjective assessment. Unfortunately, with this type of assessment, someone has to watch each student near-continuously to make sure they are doing what the watcher wants. As a system I would hate it. I would prefer to know the objectives required by faculty and have the freedom to meet these in the way that seemed best for me. I wouldn’t want my future left in the hands of a faculty member with whose approach to life and work I mightn’t agree. I think there is substance in Pickering’s criticisms of continuous assessment: (a) If it is properly done, it takes up an enormous amount of staff time, (b) It is virtually impossible to exclude personal bias from the ratings, (c) It does not permit comparison of standards across institutions or countries, and (d) Being continually assessed may cause unnecessary anxiety for the students.
My greatest worry about it is that making the teacher a constant assessor turns him from being the friend, to help the student learn, into a Big-Brother monitor. The teachers and the taught are put on opposite sides of the system and communication between them is undermined. I quite like our own arrangement where the teacher’s role is to help students reach the national standard required by the licensing body. External examiners are brought in to ensure we maintain these standards in our end-of-course assessments, and our role is to help the students to satisfy these examiners.
GENERAL
“Steps Should Be Taken to Define Objectives”
Most of us would feel that students should know what they are expected to gain from attending a course and several recommendations in the report urge us to define clearly the objectives of our courses. Few would quarrel with that. Students’ anxiety is reduced when they know what faculty expects of them, and it helps them to study. However, unless done with imagination, objectives may become a boring checklist, an imprecise paraphrase of the list of contents in the recommended text. Am I alone in finding lists of objectives so boring to read and to prepare, a tiresome exercise in pedantry? Perhaps I have never come to terms with educational bureaucracy.
“Steps Should Be Taken to Increase Resources”
There is a theory that most of our difficulties are due to lack of money; that if we had more money for teaching we would teach better and that if we had more research money we would do better research. It is a fashionable cry from those who, like myself, are well-practiced in spending public money. However, a lifetime in an education system supported almost entirely by public money has not convinced me that this is always true. In my 30 or so years in the business, our staff-student ratios have improved dramatically, the number of our technicians has gone up exponentially, our department is housed in an imposing medical centre instead of in huts, our departmental expenditure is greater in real terms than that which used to support the entire medical school. Yet I am not sure that our teaching is much better, our research is any more exciting, our sense of purpose is any greater, or indeed if we are any happier. With so much plant and personnel to look after, I, as a departmental chairman, spend more time on managerial matters than on the teaching and research I enjoy so much more.
I suspect that the university bonanza of the sixties and seventies has given us more apparatus, people, plant, and buildings than most of us can manage properly. So perhaps I should not join in the chorus for more money from the state. State spending systems tend to encourage waste and may eventually enslave us. I would be happier for the moment making better use of the money I have and, if more is needed, to see how I can earn more from what I do. If no one is willing to pay for what I do, maybe I should be looking for other work. I am not sure that the statement, “undue dependence on faculty generated money inevitably affects educational quality,” is always true. It could promote relevance.
While saying that, I still feel that some protection of academics from day-to-day and year-to-year financial pressures is essential. Medical research is a tender plant and needs sympathetic patronage. It is prone to wither in a hostile environment.
“Steps Should Be Taken to Promote Literacy”
There is widespread concern that many young doctors cannot write well and lack the language skills needed to think clearly. I don’t know whether or not this is true, but I would still give this recommendation in the report wholehearted approval. It is the key to all education. The only way I know for us to promote it is by giving an enormous amount of time to correct and correct again the literary efforts of ourselves, our students and our colleagues. No one likes having their prose corrected and few of us like to give so much editorial time for such thankless work. However, there is no doubt that the main difference between good writing and bad writing is the amount of time and effort that has been spent on it. Writing is a hard, highly disciplined craft that requires constant practice to maintain quality. It is also a skill where we should all be humble because we have much to be humble about.
Many of us as teachers set bad examples. The Journal of Medical Education is not free from verbosity; ideas may be drowned in words and many words are often used where one would do. How can we expect our students to write and think clearly if we write in the style of the following summary taken from a recent paper in an educational journal:
“The authors in this article have described the attempt of one department of family medicine to develop and evaluate a required clerkship which replicates the ethical totality of the patient-family physician relation in effective clinical practice. Special attention has been given to the methodological problem of balancing clinical integration and systematic integrity in such a way as to preserve both the relevance and rigor of ethics in clinical education. A rotation involving both the private practice and academic clinical settings has been combined with an intensive interdisciplinary seminar to develop an appreciation, understanding, and utilization of the biomedical, psychosocial, and valuational components of responsive and responsible ambulatory care.”
Another example of indifferent modern scientific prose from a government publication has kindly been brought to my notice by a former colleague, John Shepherd, who now works at the Mayo Clinic. It concerns an empirical classification of U.S. medical schools by institutional dimensions and reads:
“Based on the result of the six factor hierarchical cluster analysis, an optimal solution was sought using Forgy’s non-hierarchical cluster analysis method. The results of the hierarchical clustering were used to give an indication of the number of clusters which would represent the schools, and schools were selected as seedpoints for the non-hierarchical cluster analysis based on the hierarchical clusters. In the hierarchical cluster analysis, one school, the Mayo Medical School, appeared so dissimilar from the other 109 schools that it was not included in further comparisons. The Forgy non-hierarchical cluster analysis technique complements the Word hierarchical method by optimizing the same criterion, the sum of the squared distances of the schools from the cluster centroids, but does not maintain the permanence of cluster membership inherent in the hierarchical methods.”
It is enough to make Flexner turn in his grave; Flexner’s report should be required reading for everyone who wishes to write (and think) in medicine. Part of the problem with writing may be that we love our own words so much that having written them down, we cannot bear to throw them out. I suffer from this myself. John Shepherd made me aware of the problem and how he was helped to overcome it. Again, it did not come from attending a course on “How to write good English” but through exposure to the mind of a great teacher. In his early postgraduate days, John produced a magnificent thesis for a certain examination. It was magnificent not only in its findings but in its bulk, with its many fine diagrams and tables. After he was awarded the degree (for which incidentally he also received a gold medal), he decided to publish the work. It split conveniently into several sections, each of which he submitted as a separate paper to Clinical Science. George Pickering, who was editor of Clinical Science at the time, explained to John how the work could be described with more clarity and force if it were condensed into one short paper and he re-wrote the papers in that form for him. He showed him how to leave out all the words, tables, and pictures that only obscured the central story. One of the pictures to go was a photograph of an ergometer John had designed and built himself and to which he had a strong emotional attachment. Pickering said it was a nice picture that gave some idea of the architecture of the room but little else! This is, of course, very painful stuff at the receiving end but that is what education is about. John Shepherd has had a lasting affection for Pickering, who went to so much trouble and took so much time to help a young author. In my turn, I owe an enormous intellectual debt to John Shepherd, who passed on something of this experience to me. To write briefly is much harder than to write at length, and we cannot blame our students if we set examples of verbosity for them to follow. The hallmark of the scholar should be Flexnerian literacy. Sentences should contain no unnecessary words and paragraphs should have no unnecessary sentences. If there is nothing worth saying, one should stay silent. What better cue to stop?
CONCLUSIONS
The GPEP Report worries me a bit since it seems to embrace most of the educational fashions of our times whose efficacy in educational terms has not in many cases been proven. Though I am all for an open mind, I think we should look askance at most new educational theories, no matter how fashionable, in the near-certain knowledge that they are no more (and probably less) likely to be correct than our present ones. No system, no matter how ingenious, is any use if it doesn’t work. We would be wise in general to use only those systems where there is a prima facie case that they have worked successfully elsewhere over a period outlasting the enthusiasm of the launchers. There are few prizes and many penalties for being first in medical education. Schools that follow usually do better by benefiting from the trail-blazers’ mistakes. Perpetual change for change’s sake can undermine morale and efficiency in both students and staff and will make systematic analysis of the effects of change impossible. Evolution seems preferable to revolution as the normal means to progress; there is plenty of time. We do not need to hurry or panic about the year 2000; it is just a number and there are plenty of higher ones. In any event, what the curriculum contains and how it is organized is of much less importance than whether it encourages strong personal bonds of affection and respect, if not love, to develop between the teachers and students and teachers in different disciplines. Only in this context is real education possible. In a medical school it is the people who work there rather than the form of the curriculum that will determine in the end whether it is a good or bad school. I think we would be wiser to channel our efforts to improve medical education into ensuring that the best possible staff will wish to come to teach and research with us rather than have just one more attempt to set the curriculum on its head.
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