An immodest proposal for medical education

Right at the very beginning of their studies, medical students have strong ideas about what kind of doctor they want to be, even if they know very little about how to actually be a doctor. In one study medical students regarded empathy, motivation to be a doctor, good verbal communication, being ethically sound and honesty as the most important qualities. Medical education needs to be radically reformed if it is to support these ideals which are too easily lost.

Educationalist, Sir Ken Robinson interviewed on radio 4 last week, was asked whether he thought it necessary to master basic skills in literacy or numeracy before giving expression to language or mathematics. He responded,

“Well it’s wrong … it’s just not true. It is important that you learn these things as you go on , but this is a matter of pedagogy. I mean for example, we’re here in Liverpool, this was the birthplace of the Beatles. When they started out they knew about three chords but they had fantastic energy, compassion, enthusiasm for music. Well, nobody would deny that they became much more sophisticated musicians as they went on, but they were impelled to become more sophisticated by their passion for the music they were creating.”

He continues to say that great teachers give students a passion for their subject and their enthusiasm for learning follows from that. We need to give medical students a passion for the practice of medicine right from the first day they start medical school.

I’ll acknowledge here, that increasing numbers of medical schools have introduced patient-contact in the first year. But it needs to go much further.

The entire first year of medical school should be vocational.  Students should spend the whole year seeing how medicine is practised from the perspectives of different types of doctors, allied health professionals, managers, policy makers and most important of all, patients. They need to know what it’s like to live with a chronic disease and deal with doctors and the health and social care systems in which they will one-day work. They should learn about what it means to be a professional, about the privileges, responsibilities and stresses of their profession. They should learn from close observation and role models about the responsible use and irresponsible abuse of power. A grounding in narrative medicine and the medical humanities will be essential for them to develop the ability to critically balance such a wide range of perspectives.

They should learn about medicine’s historical, social and political roots, the role of advocacy and the importance of global health, public health and the social determinants of health.

To make sense of this they will need plenty of opportunities to meet with their peers and more experienced mentors to see how their experiences fit with their preconceptions and their ideals. This is how most medical education should happen, especially if we want our students to understand the complexity of clinical practice. These groups would be ideal fora for discussing the contested grounds of professional behaviour and medical ethics and learning about the value of narratives, the skills of peer supervision and the ability to reflect.

At the end of this year, they should be asked a question,

Which of you still wants to be a doctor?

If the experiences are sufficiently rich, both wide-ranging and deeply considered then there will be a minority who have discovered that medicine is not at all what they had expected (or it is as bad as they had feared, but had hoped it was not) and they will have the opportunity to change career before investing several more years of their life and money.

Those that remain will be much clearer than most medical students are at present, about what it means to be a professional, why medicine matters and what matters to patients.

And when they then start their basic medical sciences their ideals will be rooted in an ethically informed professional identity, a much clearer idea of their heritage and their future.

And, one would hope, their learning will be impelled by their passion.

14 responses to “An immodest proposal for medical education

  1. Another really well thought through article, leaving me thinking “if only……..”!

    And of the biomedical model?
    Pettenkoffer – ingesting cholera bacilli to show that it was not germs in isolation that kill – but the living and working conditions of those that contract them.
    Needless to say, for govt’s to address these types of issues would necessitate a fairer, more egalitarian society. It was simpler, 100 years ago, for the elite to ensure (at least in the U S) that the schools which followed a more biomedical model succeeded. Hence the modern view of pharma being the answer to all ailments and govt’s unwilling to take a broader view; take on the sugary corporations or improve housing or enable a fairer wage system etc etc.

  2. In North America young people have to do an undergraduate degree before applying to medical school. I wonder if this you make a difference and avoid some of the problems you have highlighted? And as I understand it in Canada, to become a registered physio or occupational therapist one needs an undergraduate degree first before embarking on the post graduate degree to become a physio. Perhaps delaying entry into medical or allied health schools until after an undergraduate degree would allow young people that breadth of experience to know that they had made the right decision, rather than base entrance on the number of A* exams they can cram for.

  3. Medical education is crucial and should be a national priority. The article is nice, though

  4. Well, I’m a medical student from India and all i can say about this is that most of the time a student chooses to take up THE medical profession in India is because of reasons that are not even remotely related to being passionate about the profession or patient care… Most of us were in shock when we realised what and how much this profession demands from us. And it is no wonder that this has been a major reason why doctors are forming a major chunk of people suffering from depression and such psychiatric illnesses.

    I’d personally welcome a change that involves more patient-student interaction during the initial education…

  5. What you have described is a fantastic way to enthuse and excite medical students, but unfortunately it feels like such suggestions will not be considered and implemented – at least for a really long time.

    As the medical schools around the country are increasing their intake numbers, an already competitive and exhausting course is becoming more difficult. Students should be including in medical teams, with a particular role to fulfil and responsibilities to own up to. Medicine is all about teamwork, but too often students are shrugged off, leaving them demotivated and disappointed.

    Let’s hope that such a revolution comes soon – I know I will be welcoming it!

  6. Reblogged this on Conversations I Wish I Had and commented:
    Love to read someone who expresses these ideas so eloquently. Yey you, whoever you are. I applaud you.

  7. I recommend the book ‘one doctor’ as it pinpoints some of the challenges the American health systems faces.

  8. You are so right! Passion is prerequisite in learning and in continuing education. But as you mention it also requires “great teachers” to give inspiration

  9. I agree with you completely. Nice article. 🙂

  10. Interesting comments and observations. And I mostly agree.

    I’m 20+ years from medical school (Johns Hopkins, Class of 1992) and many years into a much loved career in pathology. I’ve lectured in medical schools, nursing programs, allied health schools and to community groups. Teaching is a fabulous endeavor. Teaching and training medical students has been a hugely enjoyable experience.

    As you are well aware, the dialogue and discussions about how best to train young doctors is endless. I would agree, however, that there is near universal agreement that much of the enthusiasm and high idealism that students enter training with is lost somewhere along the way. That “somewhere” is almost always during residency training. It’s when the real work of taking care of real patients overtakes the textbook notions of what doctoring is about. Some manage to survive this period mostly intact; many don’t. And some become jaded, hostile, and mean.

    Personally, I would argue that training, per se, is not the culprit of lost innocence and idealism. It has more to do with the harsh realities of day to day practice. And I’m not sure that you can do much to inure young physicians from this reality, although there is a lot that can be done to prepare them for it. Honesty goes a long way. Seeing suffering up close is important. Reminding them that disease and social ills often go hand in hand. Poverty, tobacco, alcohol, and drugs are killers on too many levels. Care of the patient means care of the individual.

    One of my most brilliant instructors, chair of the program at Yale, and a brilliant hematologist oncologist used to jokingly remark that to be a good oncologist one needed to hate the disease more than she loved the patient. We lose sight of the fact that we’re caring for people, not just battling disease. Idealism must always be tempered with realism, although the love learning and the passion to care for others should always burn brightly.

    Peace,
    John M Fisk, MD, FCAP

  11. Reblogged this on pic&post and commented:
    Good thoughts! There’s hope!

  12. Many subjects at university require experimental, laboratory and field work to understand the meaning and applications of theories. In medicine clinical work and contacts with the patients are also essential. However, when it comes to experimental, laboratory, field and clinical exercises and demonstrations the costs of education become very high and time demanding. However, these difficulties have to be managed and it is a shared responsibility between the students and the educational institutions to have high standards of practical classes with serious engagement of students and the staff. There are, also, supplementary solutions that can be implemented in the Curriculum, either during or in connection with graduation or even after and before joining the market. Secondments, field work, study visits, internship, examination and graduation projects and coached-training are some examples. Visit, share and contribute in http://sustain-earth.com

  13. Great article, medical sciences need some focus as I.T seem to be getting all the attention

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