Born a Catalonian, I guess I am entitled to have inherited what all Catalonians claim to be a genetic trait – seny, loosely translated as “common sense”. I don’t know if it is a matter of genes or a matter of always having had difficulties accepting anyone else’s “truth?, but I am certainly bewildered (and often irritated) by some of the common “truths” waged by those involved in medical education. Let me sample a few.
1.We need to write goals and objectives for every course and every lecture
I went to medical school in the sixties. At that time, no one was writing goals and objectives. Interestingly enough, I never had any question about the goals and objectives of each course nor of the in?structors: learn the “material” identified in class and in recommended texts. Actually, it worked well, because at a very early stage I had to make my own decisions about what I thought was important and needed more attention. There is no question that from day one I became responsible for my own education -with lecture contents as my only guidance. I can understand the point about writing general goals for our courses. We always have some goals, even if we don’t try to articulate them. So why not try to put in writing what has always been in our mind? This may be actually useful when general philosophies of different courses are compared, or when courses are reviewed by external panels. But what about the detailed behavioral objectives for the course, and even for every lecture? Are we trying to define exactly what the students are responsible for? What if a question appears on the exam which is not clearly covered by the objectives? What happens if we try to be all inclusive? Do we rewrite the book or the syl?labus in “objectives” format? And who is going to provide the students with such detailed behavioral objectives in the clinical years, and more importantly, in real life?
Not long ago, this trend was even extended to textbooks, some of which started each chapter with some objectives. Fortunately, sanity prevailed in the publishing world and the practice has been all but abandoned. But there is still pressure emanating from accreditation committees and other well intentioned regulatory or advisory bodies run by bureaucrats who believe a course can be judged by its paper trail.
Going back to my medical school years, I re?member well that my perception of different courses was widely different, and had nothing to do with stated or perceived goals and objectives, but a lot with the personality of the instructor. My first enthusiasm was pathology, and in no small measure was due to excellent faculty. My second love was cardiology, again following the role model of one of my instructors, who happened to be an excellent cardiologist. My final choice was research, having nothing to do with role modeling but just with my own experience and my own decision – one tends to grow up. The faculty that influenced me as a student were ex-cellent teachers, some gave excellent lectures, others were better in small groups (nothing is new under the sun), but all of them contributed to the good quality of the courses they ran or took part in. And none of them wrote a list of objectives, ever. Indeed, if any?one wishes to judge a course, he/she needs to take it as a student, sit through lectures, participate in small groups, and take the tests. Most paperwork exercises are useless wastes of time, and writing detailed be-havioral objectives is second to none.
2.Lectures are useless
Having expressed my reservations about lectures in this platform, let me now defend lectures for a moment. There are lectures and there are lectures, depending on who gives them and on the student who listens. I never thought that attending a good lecture was wasting time. I took detailed notes, and most of my learning happened in the classroom. I know of others like me, we must be good visual and auditory learners, and by taking notes we concentrate on the events and tend to remember the facts and contents of the lecture for a reasonable amount of time. Why is it so difficult to recognize that there are some problems with lectures that have nothing to do with the format? Number one, a boring lecture is a waste of time. So is one so detailed that it is beyond the level of under?standing of the audience. It is also wrong to go to a lecture with a passive attitude, waiting for entertain?ment. Lectures should not become one-act skits for the sake of those ill prepared to concentrate. Having said so, my common sense position is simple: lectures should always be trusted to competent lecturers, should be general and conceptual, and the students should be actively involved – by that I mean the old fashioned methods of taking notes, asking and an?swering questions! A judicious blend of good lectures and active learning formats is the recipe for success in medical education, in my opinion — based on 20 years of experience as a teacher, and zero years of experience as a professional educator.
3.It is better to teach someone to fish than give him a fish to eat
I know of nothing as dangerous as trying to see the truth in proverbs, Chinese or otherwise. Even more dangerous are inane proverbs, such as the fishing proverb. Let me clarify that I have nothing against learning how to fish… I once went out to the lakes with an experienced fisherman, and I learned how to catch fresh water fish with plastic worms and how to rig a hook to avoid entangling it on weeds. But when I tried to translate this learning experience on my own, fishing at the ocean surf, I met with un?mitigated frustration. With time I realized that everything I had learned was useless when it comes to fish in the ocean surf. Ocean fish could not care less about plastic worms or any plastic bait in general. I sought the advice of experienced salt water fishermen and I was advised to use shrimp as bait, but since I would rather eat the shrimp myself I tried other types of bait. Cut mullet and small minnows worked to some extent. What I ended up catching were small sand sharks, ocean catfish, the occasional stingray, and very, very rarely, an edible fish. If I had to survive on what I fish, I certainly would have to change my feeding habits. So, can we really apply this fortune-cookie proverb to medical education, trim the exposure to factual information to a bare minimum, and expect the students to become able to dig facts they never heard of, to think of diagnoses they never read about in a textbook (rare diseases, who cares?) etc. etc.? I say go easy on the fishing proverb….
4.Multiple choice exams are terrible evaluation tools.
In my medical school all exams were oral, mostly one shot at everything as a final, all encom?passing exam. Talk about pressure! But one does what one has to do, passed them with variable suc?cess, and no long-lasting harm happened to me. When I first became exposed to multiple choice exams, it immediately struck me that they had some great advantages: everyone took the same test, everyone was graded equally. Only those that lived on a diet of oral exams may appreciate how important those advantages are. To this day, no format has been developed that can boast of these two attributes. But we keep hearing the education folks coming down hard on multiple choice exams. Indeed, I have seen some terrible examples of multiple choice exams, but the solution appears to be working to improve the items and develop questions that probe for other than mindless memorization, still based on the multiple choice format. The National Board of Medical Examiners has given the example of continuously working to improve the questions, and everyone could learn from their excellent staff, willing to share their experience with anyone that wants to listen. And there is something else we should never forget: all Board exams (in medical school and afterwards) have at least a very significant multiple choice component (if not exclusively based on a multiple choice exam). So what good will it do the students to train them in all types of test formats that they will never encounter on a meaningful exam? Again, a dose of pragmatism is urgently required.
5.There’s too much science in the first two years
This is the basis of the paranoia surrounding medical education reform. There is a feeling that someone is trying to do away with all the courses run by nerdy scientists and promote early exposure of the students to real life docs; let’s emphasize interpersonal skills, humanism, ethics, etc. The rest, they will get as they need. Well, in case someone really thinks this way, I beg to dissent. I think we teach science too superficially to a group of students with very diverse backgrounds (many schools have dropped all requirements for pre-medical courses). For some students, the exposure to basic sciences in medical school will be all the organized exposure to science they will get in their years of higher education. It is almost impossible to train naive students in the scientific method and to give them a true appreciation of the impact of research and scientific knowledge in medicine within the framework of the first two years of medical education. If this time is to be used otherwise, then we have to make sure that the students get their science education in college and that even some of the classical contents of medical courses are transferred to pre-medical education. But the idea that a student who majored in political science (as an example; there are many others) can truly become a thinking physician with minimal exposure to science is preposterous. Medical School is not trade school, and it is in the interests of patients, students, and professionals to strive to expose students to the most updated and comprehensive basic science experiences that can be fit into the constraints of our curricula. Adding additional constraints will inevitably lead to graduation of physicians unprepared to think scientifically, to understand the basis of their actions, and unable to keep up with developments which will bring molecular mechanisms more and more into the forefront of our clinical practice.
So, this is a short digression into a crowded minefield, picking apart just a few of the obstacles. My intent is to be provocative, to open up arguments. These are important topics and we need to discuss them. Otherwise, more and more of the decision malting concerning our courses and curricula will be transferred to individuals with limited practical experience in medicine or in the teaching of medicine–which is cause for great concern.