Medical education is difficult, and there are no shortcuts. Here are Dr Sutter’s views on medical education and five principles concerning its implementation.
I have been learning medicine for more than 50 years and teaching and practising it for more than 45 years. The thoughts that follow are derived from these experiences.
As with most human endeavors, the practice of medicine is a mixture of rote and reasoned behavior. Learning and teaching medicine must be a similar mixture. The skill of the practitioner or student is to know which type of behavior to use at a particular moment for a particular problem.
Learning medicine consists of learning a new vocabulary, then using that vocabulary to become fluent in a new language while gaining information. The final step is to use the information and language to solve medical problems. I do not think that the learning process can occur in any other sequence. The passage of time and integrative thinking are necessary to use the language well. Problem- or case-based learning is simply an attempt to provide an incentive and context to the learning process.
Medicine can well be learned in a master-apprenticeship system, as it has been throughout most of history. The difficulty is that there are relatively few good masters and an apprenticeship system is susceptible to fads, bias, and corruption. The Flexner Report of 1925 was a response to such a situation. The resultant reforms that placed medical education exclusively in the universities in North America attempted to correct the problem by reducing the apprenticeship aspect and increasing the “scientific” content. The current trends are to increase the apprenticeship content, to introduce it earlier, and to call it clinical. This is a risky endeavor and could lead us back to the problems that existed prior to Flexner.
Problem-based learning is an attempt to introduce a master-apprentice relationship without calling it that and without the responsibility that a master ordinarily has toward his or her apprentice. The ratio between numbers of masters (tutors) and apprentices is absurdly low in the problem-based system, but even then it is costly in time and resources. The evidence that it results in better practitioners is virtually nonexistent, and there is good evidence that the students in such a system are lacking in information.
Medical education is difficult, and there are no shortcuts. It is particularly unfortunate that there are strong pressures at present to shorten the process because of both licensing requirements and cost.
I believe in the following principles of medical education:
Allow enough time
Time is important. The amount of time allocated to a subject must be proportional to its importance in the practice of medicine. Considerable time also is required, regardless of what is taught and how it is organized, for integration of a subject to occur in the student’s mind. Integration cannot be forced; it is the product of time and the thinking of the student. If medicine is learned by subjects organized as traditional disciplines (pharmacology, physiology, etc.), then the information must be integrated into systems (cardiovascular, endocrine, nervous, etc.). The reverse integration must occur if the initial organization is according to systems. Regardless of whether subjects are taught by discipline or by system, integration is a slow, painful process dependent on the student and requiring a period of time that cannot be reduced beyond some minimum.
Provide ready access to teachers
The student should have ready access to the teacher and should be encouraged to make use of this access. This is best done by a formal method such as the system at a university such as Cambridge where weekly essays are required from the student for presentation to the supervisor at weekly “supervisions.” I recognize that this is expensive in terms of time and resources, but we should not delude ourselves that we have a superb system if we have less than this.
Provide a good examination system
Examinations are important. They should be frequent enough to obtain an adequate sample of the student’s ability. The examinations should be set by more than one individual, and if the examinations are subjective they should be marked independently by more than one individual. Final examinations should be set by an organization external to the department (or group) teaching the course. Ideally examinations should be of more than one type. The least reliable are oral (viva voce) examinations.
Rate teachers based on student performance
Assessment or rating of teachers should be by external assessment of the performance of students who have taken a particular course. Students’ comments can be useful when they are obtained some years after taking a course; ratings by students enrolled in a course are inappropriate for most purposes.
Involve students in research
We do a poor job of providing an opportunity for students to learn how difficult it is to obtain reliable data in the laboratory or clinic. A solution to this is to involve all students in actual research projects. It is not sufficient only to do literature-based research on a topic because this does not compel assessment of the data itself or how it was obtained. We are turning out a group of practitioners who might be socially aware but who are scientifically naïve.
We must do better. The ubiquitous presence of masses of information on the World Wide Web makes it even more imperative that knowledgeable, skeptical, and compassionate physicians be the result of the medical educational process.
Morley C. Sutter, MD, PhD
Dr Sutter is an emeritus professor and former head of the Department of Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia.
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