You don’t learn to draw by knowing how pencils are made
These sort of aphorisms always make me to want to think harder about what exactly is foundational in medical education. The suspicion is that it is far less than we think. Schooling is full of wasted time spent learning things that are of little use, but easy to test, meaning there is little time for students to learn things that are useful.
The case for anatomy in surgery is robust and self-evident. If you remove tumours in the preauricular area or on the temple, you have to know what structures to avoid or which ones may have become compromised. If you ask any competent surgeon they will of course know what these structures are. But when you move into many areas of clinical medicine, I am always amazed by how much competent physicians have forgotten about all these things that were labelled ‘foundational’, and formed the basis of high-stakes exams. It is of course possible to be aware of schema, that structure your behaviour, and be unable to recall them — schema that experts implicitly know and novices don’t. But I suspect we need some sort of minimalism project, to work out how far we can go.
I was browsing through some old noes and came across this:
Third, we’re convinced that medical education and training must be reinvented to adapt to the changing health care paradigm. We think that AHCs should reexamine traditional beliefs and approaches to medical education, questioning its cost and duration. Should education shift toward using dedicated instructors, increased online instruction, simulation, even gaming? Can AHCs shorten training time by streamlining the educational continuum — for example, providing a focused 3-year medical school curriculum in primary care, plus a 2-to-3-year residency?
“Physical exam skills are eroding fairly significantly. We see that year after year. The masters who taught us are gone, and we’re not teaching the people below us well enough, for all the reasons we talked about.
At the same time, we grossly overestimated the average clinician’s ability to do an extremely good physical exam and to make all of the relevant physical findings. It has been documented over and over again that the average person’s ability to use a stethoscope and document a murmur accurately is a coin flip. The ability of the average house officer to do volume assessment based on a physical exam is terribly low.”
So, you are interested in medical education? Discuss.
The survey found that UK medical schools employed 3041 full time equivalent clinical academic staff employed by UK medical schools, with a headcount of 3361. This is a 2.1% decline since 2015 and a 4.2% decline since 2010. By comparison, since 2010 the number of NHS consultants has risen by 20.6%.
Reform of, and improving how we educate medical students requires a rethink of medical school staffing, and how clinical academics work. There are plenty of heads in the sand. I think you can improve education and drastically cut costs at the same time. Just stop accelerating into the rose tinted image in the rear view mirror.
This can be read as typical Silicon Valley hype, but I think it is more right than wrong. Just as government thought computer education in schools was about using MS Office, too many in higher education think it is about copies of dismal Powerpoints online, lecture capture, or online surveillance of students and staff. The computer revolution hasn’t happened yet. Medical education is a good place to start.
What can we do to accelerate the revolution? From our observation, the computer revolution is intertwined with the education revolution(and vice versa). The next steps in both are also highly overlapped: the computer revolution needs a revolution in education, and the education revolution needs a revolution in computing.
We think that, for any topic, a good teacher and good books can provide an above threshold education. For computing, one problem is that there aren’t enough teachers who understand the subject deeply enough to teach effectively and to guide children. Perhaps we can utilize the power of the computer itself to make education better? We don’t hope to be able to replace good teachers, but can the computer be a better teacher than a bad teacher?
How to select medical students…………..
On the topic of quotations, though, a longer recent discussion about Hanlon’s Razor on the Farnam Street blog includes this rather nice one from the German general Kurt von Hammerstein-Equord:
I divide my officers into four groups. There are clever, diligent, stupid, and lazy officers. Usually two characteristics are combined. Some are clever and diligent – their place is the General Staff. The next lot are stupid and lazy – they make up 90 percent of every army and are suited to routine duties. Anyone who is both clever and lazy is qualified for the highest leadership duties, because he possesses the intellectual clarity and the composure necessary for difficult decisions. One must beware of anyone who is stupid and diligent – he must not be entrusted with any responsibility because he will always cause only mischief.
Jed Mecurio was on Desert Island Discs. He of ‘Cardiac Arrest’ fame. (ITU: they used to call it the ICU — intensive care unit — till they realised, nobody did). Something he said chimed with a conversation I had with somebody who knows a lot more about junior doctor training in the modern NHS than I do.
Mercurio, was the son of working class Italian immigrants. And, as is true of many immigrants, a child moving into the stable world of the professions is encouraged. Mercurio pointed out that the popular representation of medicine often does not match the reality. Those with family members already in medicine know this, whereas those without this, have to discover it (at least, I hope they discover it).
When I was trying to get a handle on some of the issues surrounding junior doctor training with my source, the very same point came up. Many junior docs idea of what medicine was like, he / she argued, was based on TV programs — and more Eastenders than West Wing. And this is a problem, he commented.
Cardiac Arrest may be showing its age, but for me it was more accurate than all the sanitised bumph that medical schools and the GMC produce. Fiction is sometimes more real than reality.
One of the important things I learned from reading Herb Simon’s ‘Models of my life’ was his view that seldom did reading the academic literature feed him with new ideas on what to work on. I do not mean to imply that reading the literature is irrelevant, but that in some domains of enquiry the formal literature is often unhelpful when it comes to not so much thinking outside the the box, but realising the box needs throwing out and you need a chair instead. For instance, in med ed, I find most of the formal literature akin to chewing sawdust. It is dull and often the main motivation seems to be to advance one’s career rather than change the world. All of this came to my mind when I read the following:
It tells the remarkable tale of Athletic Bilbao, one of three clubs never to have been relegated from La Liga, the Spanish top division, despite having a policy of selecting only Basque players. Bilbao’s story emphasises a recurring theme of the book: the importance of development programmes for young players and the lengths that clubs go to in order to nurture footballers. Benfica, a Portuguese club, uses a 360-degree “football room”, walled by LED lights, to train players in over 100 scenarios. Targets appear for the players to hit with the ball; sensors measure the players’ effectiveness.
( a review in the Economist of The European Game: The Secrets of European Football Success. By Daniel Fieldsend. Arena Sport; 255 pages; £14.99.)
Now, readers will know that given the genes, I am more rugby than soccer, although I marvel at the skill modern footballers show. But what interests me and has interested me for a while is the relation between structured unnatural performance and fluency at performance. Now my phrasing may be a little ugly, and I do not think there is anything deep or new about what I am saying. Just take how we know you learn a musical instrument. How breaking up and sequencing of mini skills is necessary before you put it all together. People do not pay to listen to people play scales (although I will ignore, shred guitar aficionados), but rather they like songs or sonatas etc.
I would push this is the following direction. A real danger in undergraduate medicine is that we have become inured to the idea that learning situated in the clinic is the best way to learn medicine. At one time, I might have agreed. But out clinics have changed, but our ideas have not. One of the benefits of coaching and online learning is that we can make the offline — the clinic — work better. But also need it less, because it is not working well.
There are some interesting apparent paradoxes here. We need (pace the above quote) more ‘football rooms’, but as Seymour Papert argued, if you want to learn to speak French go to France and if you want to learn maths go to mathland. But are these real or virtual?
There are two models. Sage on the stage. Or building structures than scale. Individual brilliance and interpretation; or Hollywood. There are not not enough sages; but people deny we can build structures that scale.
I see this dialectic everywhere in education. When do we need n=1; and what can do at scale. It is not just education however. All over the creative world we can see this battle play out. As Paul Simon put it:
“I’m sittin’ in the railway station, got a ticket for my destination
On a tour of one-night-stands, my suitcase and guitar at hand
And every stop is neatly planned for a poet and a one-man band”
On the other hand look at this. The song maker (Max Martin) few have heard of.
Woodie Flowers in a devastating critique of MITx said it well.
I believe the “sweet spot” for expensive universities like MIT is:
1) access to highly-produced training systems accompanied by
2) a rich on-campus opportunity to become educated.
MITx seems aimed at neither.
Medicine gets this confused big time. There is training and education. If we did the former better, we could offer a real education. But to do the training better, we need scale. And that means content. We could do things better and cheaper.
Institutions with histories matter. It is just that in many instances innovation often comes from the periphery. I think this is often true in many fields: science, music, even medical education. It is not always this way, but often enough to make me suspicious of the ‘centre’. The centre of course gets to write the history books.
An article by Mark Mazower in the NYRB, praising Richard Evans, the historian of the Third Reich, caught my attention. It seems that nobody in the centre was too excited about understanding the event that changed much of the world forever. Mazower writes:
If you wanted to do research on Saint Anselm or Cromwell, there were numerous supervisors to choose from at leading universities; if you wanted to write about Erich Ludendorff or Hitler, there was almost no one. The study of modern Europe was a backwater, dominated by historians with good wartime records and helpful Whitehall connections—old Bletchley Park hands and former intelligence officials, some of whom had broken off university careers to take part in the war and then returned.
Forward-looking, encouraging of the social sciences, open to international scholarship from the moment of its establishment, St. Antony’s is the college famously written off by the snobbish Roddy Martindale in John le Carré’s Tinker, Tailor, Soldier, Spy as “redbrick.” The truth is that it was indeed the redbrick universities, the creations of the 1950s and 1960s, that gave Evans and others their chance and shaped historical consciousness as a result. The Evans generation, if we can call them that, men (and only a very few women) born between 1943 and 1950, came mostly from the English provinces and usually got their first jobs in the provinces, too.
It is interesting how academics who had had career breaks were important. And how you often will need new institutions to change accepted practice. All those boffins whose careers were interrupted by the war led to the flowering of invention we saw after the second world war. You have to continually recreate new types of ivory towers. But I see little of this today. Instead, we live in an age of optimisation, rather than of optimism that things can be different. The future is being captured by the present ever more than it once was. At least in much of the academy.
Some nice memes in this letter from an MD student in Australia. Please discuss. Pharma might be interested
Considering this, if we thought about the pervasive attitudes that inform our definition of a “good” medical student as a disease, it’s hard to believe that we would not try to treat it.
This is from a book review on the ‘birth of cool’, by Robert Eaglestone in the THE.
Despite laying out some principles (“cool is…”), the book focuses on honed case studies of “the saints of cool” (as Hannah Arendt argues, we learn more from examples than from principles).
This little gem was new to me —but not the concept, or the principle…..
Academia tends to love rules, and formal systems, but for some domains of competence, they are grossly overrated. Formal logic is often not what is need, and we may seem more with a metaphor. Alan Kay’s aphorism: a different perspective may be as valuable as 80 IQ points.
I saw this giant problem in my education, and I actually designed a course called, “Physician Heal Thyself, Evidence-based lifestyle.” I brought in all these doctors who are experts in sleep medicine, sleep, fitness nutrition, food as medicine, functional medicine, integrative medicine, osteopathy and acupuncture. I got them all in a room and said I want you to teach students what we’re missing. We need to make this medical school education and have to implement this into the board certification programs as well as board exams. If it’s not required, it’s not going to be taught.
No, I am not taking this too seriously. Awhile back, I compiled a list of all the things we needed to
inflict on / ask medical students to know : I had to buy a larger hard drive. And as for this ‘new medicine’ George Bernard Shaw described it a long time ago.
I began as a university student after two years of military service. My brain was like an empty sponge. University was fantastic, a world full of knowledge and very interesting people. I studied medicine and went to philosophy lectures as much as I could, and then mathematics until my medical exams came up.
Wolfram Schultz in the THE
senility vanity, but I remember being taught by an ‘ancient’ GP in my first year of med school, in 1976. His name was Andrew Smith, and most of us thought him amazing in many ways. One of the stories that made a deep impression on me, was how— the day after he graduated — he was delivering a baby using forceps in the mother’s own house at 3am. I would have been 18 or so and he in his early sixties —not far from where I am now. So, he would have been a medical student in the late 1930s, and I will probably stop practising medicine in the early 2020s. When I add the two professional lifetimes together at the extremes (med student to final year of practice) I am always amazed how big the number is — a span of 80 years or so. And one of our problems in undergraduate education is that we have to be concerned with these extremes: I am teaching students who will practice for another 40 years, but I have inherited a set of code written as many years in the past.
Now the above reminisce was set off by some words from Benedict Evans. He is talking about much shorter timeframes and is concerned with the commercial world. But my question for medical students (and others) is how is medicine really going to look in a few more score years, and how do we imagine all the system wide interactions that will make the future so different? This is surely more meaningful that memorising biochemical pathways.
“Everything bad that the internet did to media is probably going to happen to retailers. The tipping point might now be approaching, particularly in the US, where the situation is worsened by the fact that there is far more retail square footage per capita than in any other developed market. And when the store closes and you turn to shopping online (or are simply forced to, if enough physical retail goes away), you don’t buy all the same things, any more than you read all the same things when you took your media consumption online. When we went from a corner store to a department store, and then from a department store to big box retail, we didn’t all buy exactly the same things but in different places – we bought different things. If you go from buying soap powder in Wal-Mart based on brand and eye-level placement to telling Alexa ‘I need more soap’, some of your buying will look different….In parallel to this, TV, which so far has not really been touched by the internet, is also starting to look unstable.”
Nice letter in Academic Medicine. Not convinced by the exact details, but the author is on to something important. The first victim of insincerity is language (Orwell, if I remember correctly).
Medical professionalism is espoused as a necessity in health care, setting an important precedent of excellence and respect towards peers and patients. In many medical schools, a portion of the curriculum is dedicated to the intricacies of medical professionalism. Though typically taught through specific tenets and case studies, professionalism is still a general principle, resulting in varied definitions across institutions. This is, in fact, part of the beauty of professionalism—the lack of definition makes it a flexible concept, applicable in a wide variety of situations. However, the downside to this vagary is that it allows for the weaponization of professionalism, leaving space for “professionals” to reject certain approaches to health care.
Comment on an FT article. How things have changed. Even I can remember a colleague — a few years my senior — who went for a Wellcome Training Fellowship, only to be interviewed by one person, with the opening question being, ‘Imagine I am an intelligent layperson: tell me what you want to do!’
I was a war baby, a small farmer’s son and in 1960, at 17, I had a chat with my most trusted teacher about what I should do to apply to become a doctor for which I had just acquired a good group of Scottish highers. He advised me that because I should have applied a number of months before, to write a letter to the University enclosing my qualifications. I was asked to come and have a chat with the Bursar and the only thing I remember him saying was that my qualifications were good but did I realise that I might be preventing somebody else from getting in. I am ashamed to say that I replied that I was not really too troubled about that. I was accepted, and was fine.
When you want to find your way around a city, you might memorise key streets or more likely use a simplified map as a guide as you travel. But when you know a city, you navigate by being able to recall how you get from A to B. In fact you may have difficulty drawing a map — certainly to scale — but your memory is made up of lots of instances of what lies around a particular corner. Much of what you learn about diseases is the map in this analogy. By contrast, what the experienced clinician knows are lots of instances of what lies round particular corners. Those instances have a name: they are called patients.
You cannot change or reform undergraduate medical education in a significant way without changing the way doctors work and behave.
I keep coming back to a few central insights that have — in the best sense of the word — disturbed my world view. These are from a wonderful article in a journal I had never heard of, written by Frank Davidoff. (But I do not buy the term ‘revolution’)
Competence, in contrast, is like “dark matter” in astronomy: although it makes up most of the universe of working knowledge, we understand relatively little about it. What does it really consist of? Which of its components are most important? How do people acquire it? What’s the best way to measure it? And how can you tell when they have enough of it?
Most importantly, it is increasingly clear that competence is acquired primarily through experiential learning – a four-element cycle (or spiral) in which learners move from direct personal involvement in experiences, to reflection on those experiences, integration of their observations with sense-making concepts and mental models, and finally back to more experiences. Formal training for all high-performance (applied) professions, for example, music, architecture, theater, and athletics, is grounded in the unique requirements of experiential learning: case-based coaching, rather than lectures by content experts; hands-on, practicum experiences (including simulations, if necessary) in addition to written end-objectives; repeated experiences and outcome evaluations over time rather than initial, one- shot exercises; and, ultimately, acquisition of the advanced skills of “reflection-in-action,” which is required for high-level performance and “reflection-on-action,” which is required for continued self-evaluation and self- instruction (Schon, 1987).
Mens Sana Monographs:2008 | Volume:6 | Issue:1 | Page:29–40
Focus on Performance: The 21 st Century Revolution in Medical Education
Bruce Alberts talks a lot of sense about science education and education in general. And of course he produced a book that ‘educated’ a whole generation (or more) of people like me. But in this recent Science piece he is taking on some of the big questions, questions that have been asked before, but for which few have managed to follow through on. As ever, the emphases are mine.
In previous commentaries on this page, I have argued that “less is more” in science education, and that learning how to think like a scientist—with an insistence on using evidence and logic for decision-making—should become the central goal of all science educators. I have also pointed out that, because introductory science courses taught at universities define what is meant by “science education,” college science faculty are the rate-limiting factor for dramatically improving science education at lower levels.
For example, there is a long-standing belief that every introductory college biology course must “cover” a staggering amount of knowledge. There is no time to focus on a much more important goal—insisting that every student understand exactly how scientific knowledge is generated. Science is not a belief system; it is, instead, a very special way of learning about the true nature of the observable world.
His phrase, “college science faculty are the rate-limiting factor for dramatically improving science education at lower levels”, could equally apply to medicine and medical teachers. It is not hyperbole to say these are some of the central problems of our time. And it is not just science education that is the issue.
“Core surgical training in the UK has been dubbed “core service training” because many trainees believe it does not provide enough surgical experience. At the southern tip of Africa, I felt I was being taught to operate, not to just watch and hold retractors. My commitment and progression were judged on hard work and merit, not on how many courses I had attended.”
A little awhile back after a teaching session, I asked — as I often do — a googly: ‘What is the worst thing about being a medical student?’ The response: ‘Feeling like a spare part’.
My quick and facetious response was to argue that at least spare parts were useful, whereas students were (usually) not. The humour was appreciated 🙂
But if you think this through, it is possible to argue that students are indeed less useful than they once were. At one time, final year students were a key component of clinical service. They clerked people, they could insert iv lines, write up drugs, and they were around long enough in one environment for people to make meaningful judgments of their abilities and remember them. And to be able to trust them. They could do paid locums, and even when they were not being paid, they could not be absent, nor did you need to formalise start and finish times. One of my colleagues reported that he used to be able to ‘prescribe anything apart from diamorphine’ as a final year student.
This all raises some interesting questions
Medical education is indeed always advancing: but many of us think it is increasingly out of phase with the world we live in. Magnitudes matter.
I have a secret admiration for some aspects of surgical training. We all know the bad ones, so I do not need to talk about them. When Lisa was doing her Mohs’ fellowship, it was the following vector: you watch X procedures, you perform Y procedures under supervision and you then perform Z procedures ‘independently’, with help on hand. After that, you keep learning. Sensible, and has the essential character of what has been known about craft apprenticeships for over one thousand years: apprentice; journeyman; master. This BMJ piece by a urologist asks:
If you were applying for a certificate of completion of training (CCT) in urology in 2015 you had to have seen or assisted in at least 20 radical prostatectomies before being signed off as competent. A year later, for no apparent reason, it appears that 10 will do.
He then goes on:
Standing in a theatre, unscrubbed, so you can say you’ve seen a procedure was never a part of surgical training, nor should it be now. It has no value. Unless you are very good at the procedure already and you are learning nuanced techniques from a master surgeon, watching a procedure will never make you a better surgeon.
Now, I despair of this sort of thing even when we ask medical students to do it. Why, is the question? What value is there, in watching? That this is considered meaningful at this level of training is even more worrying. And of course the figures will be pushed down, over time. This is the NHS, after all; never let expert judgment get in the way of a political imperative or somebody paid by the government: “we have to revise the speed of light for operational reasons….”
There is a more subtle point which makes thinking about the article even more worth while.
Trainees should spend their training doing the things that they’ll be spending their lives doing, not watching procedures they will never perform.
Now, it is clear that the current bull coming out from HEE, NHS, Deans etc is that we don’t need experts anymore, just people to cope with whatever disease is the flavour of the month (that there are demographic changes — pace the lectures I received from John Grimey Evans in 1976— was apparently not obvious to NHS managers or Jeremy Hunt till late 2016). Here is a problem.
When people finish formal training they are not as expert as they will be in 10 or 20 years. I do want an experienced dermatopathologist to be reading the samples I sent him. Wisdom is not the sole preserve of the old, but in many craft or perceptual disciplines I know about, the old guys and women do it better. So, problem one, is that when people come off a training scheme they are not the doctor they want to be. They are not qualified, they are just setting out, able to work without immediate supervision — as they choose and judge. This is the ticket.
The second problem, as the author makes clear, is that the training schemes are wasteful and not geared to excellence. Again, in a world of ‘pull’ (John Seely Brown’s phrase) the NHS is still trapped within the metaphors of the same industrial age that Donald Trump thinks is going to bring all those jobs back.
We have lost our way in much of what is important in medicine. It’s time that we focused on what really makes a surgeon better and stopped the pointless processes that surround training
Amen. But the surgeons have got some things going for them. IMHO many other branches of medicine are much, much worse.
Nice paper by Erik Driessen, and much more nuanced that my quotes might suggest. Worth a read. But still a phrase that I use as a bullshit detector.
Many students do not value reflection as a learning strategy, especially not when they are forced to use an artificial and fixed format and they have little opportunity to direct their learning as a result of these reflections.
“Few things seem to irritate doctors and medical students so much as mandatory reflection. (Tomlinson 2015)”
Twenty-five years of portfolio reveal a clear story: without mentoring, portfolios have no future and are nothing short of bureaucratic hurdles in our competency-based education program
But I do prefer the term ‘learner chart’, but why not just say, ‘a record of what you did’, just like handing a lab book in. Once again, school teachers might be our guides.
People who make predictions of how many doctors or even what specific type of doctor we need in (say) 20 years are IMHO generally deluded. Or they are telling fibs. Or selling something. The following is from the NEJM and is about ‘hospitalists’
Twenty years ago, we described the emergence of a new type of specialist that we called a “hospitalist.”. Since then, the number of hospitalists has grown from a few hundred to more than 50,000 — making this new field substantially larger than any subspecialty of internal medicine (the largest of which is cardiology, with 22,000 physicians), about the same size as pediatrics (55,000), and in fact larger than any specialty except general internal medicine (109,000) and family medicine (107,000). Approximately 75% of U.S. hospitals, including all highly ranked academic health centers, now have hospitalists. The field’s rapid growth has both reflected and contributed to the evolution of clinical practice over the past two decades.
The only way you can play ‘make believe’ like the DoH and all the NHS ‘experts’ so keen to trample all over our medical students’ futures is if you think Stalin is still alive and sorting out the tractor numbers.
I have written before about the problems that learning outcomes fail to deal with (Jorge Luis Borges and learning outcomes), but there is another cognate issue that bugs me from time to time. The following is a quote from The Undercover Economist in the FT
Should the rules and targets we set up be precise, clear and sophisticated? Or should they be vague, ambiguous and crude? I used to think that the answer was obvious — who would favour ambiguity over clarity? Now I am not so sure. Ponder the scandal that engulfed Volkswagen in late 2015, when it emerged that the company had been cheating on US emissions tests. What made such cheating possible was the fact that the tests were absurdly predictable — a series of pre-determined manoeuvres on a treadmill.
I think there is a very clear downside to making too precise what it is that students should learn. I actually think we need noise in the system, simply because assessment methods are imperfect and unnatural, and the more you seek particular psychometric qualities the greater the distance between what is important and what and how you test. This is not a popular position to take, and I confess I am one of the worst offenders in terms of producing tightly defined content. But if:
assessment drives learning
the I would add, to make a couplet
assessment wrecks learning
Not so long ago, at an internal meeting, the message was ‘things are tough for this year, and next, but after that all the tightening and discipline will pay off, and things will get back to normal’. I doubted that at the time, and stick to my conviction that things are going to get a lot worse for much Higher Education in the UK. There is plenty of blame to go around: institutions have preferred their own propaganda to reality; they have allowed their business (sic) to grow fat on subsidies; and they have lost touch with the academic ideal. Most of all, they have failed to keep with up the rate of societal and technological change — ironic, since this is a world that universities, more than any other institutions, created. As we can see so bluntly in medical education (for an egregious example, just read this recent editorial in the BMJ), governments view universities not as meaningful components of a healthy society, but as providers who are required to do contract work for the government. The more the students have to pay for their own training rather than their own education, the better. The independence of many or most universities is illusory. They are like temporary post-docs, jumping from grant to grant, doomed to follow the ideas of others: renters not home owners. The institutional question remains: where do you position yourself? And how.
(Wonke has a little on some vibrations — aka shocks — that will only become bigger)