Dr Ezekiel Emanuel whose job at the University of Pennsylvania is to think deep thoughts has a short piece just published online in the JAMA. In it he observes, rightly I believe, that the internet has changed the first two years of medical such that most teachers are no longer needed. The first two years of medical school are devoted to the basic sciences. Few students go to the lectures that are given by the physiology, biochemistry, etc departments because they can be viewed online. Ezekiel also observes that the basic science curriculum is being shortened. If the student is going to get his lecture experience online it might as well be from the best teachers irrespective of where they work. He develops this thesis and you can read it yourself. I think, however, that he has missed a central point about the education of a doctor.
Medical students don’t learn much more than the jargon of the profession during their undergraduate education. It’s telling that medical school is considered an undergraduate institution. Think about this nomenclature. What would be considered as a graduate school in any other course of study is considered undergraduate education when the subject is medicine. The real learning comes after graduation in residency and fellowship programs. In nephrology a knowledge of physiology, biochemistry, and immunology is central to mastering the discipline. When a new fellow arrives we assume, rightly or wrongly, that he knows little or nothing about these subjects and therefore teach them from scratch.
In essence we are acting, even if we don’t say so aloud, as though the two years spent studying the basic sciences were largely a waste of the student’s time. So OK, shorten the time as much as possible. Use the internet as Emanuel describes, but don’t deceive yourself into thinking that something will not be lost in the process.
With legions of medical educators depending on the current system to sustain their livelihoods, they will not adapt to change easily. That medical school, especially the first half is essentially superfluous will be greeted by them with defensive scorn. I’ve quoted my beau ideal about education here several times before, but he’s worth repeating. “Nobody can teach you nothing. You’ve got to learn it for yourself.” The author of this profound insight is Willie Mays.
What does a great teacher do? He helps the student learn the material on his own. At his very best the master teacher inspires the student to go beyond what he thought was his limit. Consider the greatest medical educator I know of – the late Donald Seldin; the man who built Southwestern Medical School into the great institution it is today.
Watching Seldin teach on a computer is akin to listening to Caruso on an acoustic recording. You can tell something is there, but the reality of a live experience is lost. Seldin’s impact was personal and in the room. He asked his students questions as he explained a difficult case or physiological problem. Learning was a joint effort. A recorded lecture on the internet may help you pass Part 1 of the National Board exam, but it will yield nothing lasting. The exam itself is no longer meaningful which is partly the reason it’s being turned into a pass fail score. It’s about on the level of the test an immigrant takes to become a naturalized US citizen. “Who was the first president of the United States?” would fit on either test.
Dr Emanuel’s plan for remote learning will likely take root – medical school as a correspondence course. This would be a major backwards step if medical school really were that important. The real teaching which will of necessity be hands on will take place after the award of the MD degree. If the medical student has acquired the habit of learning it for himself as an undergraduate his med school education will have been a success.
Back to Seldin. An encounter with him – live not on a recording- was a stressful event. The student knew he had to be prepared. And when he didn’t know the answer to one of his basic questions about a patient’s disease or the process behind it he found the answer on his own as quickly as he could and likely remembered it for the rest of his life.
The medical curriculum is filling up with a lot of touchy feely stuff that likely will do no harm and will keep a lot of professional educators employed. These are well meaning people who are not skilled in science or clinical medicine and thus turn to education as a vocation. The phenomenon is not unique to medicine. They’re everywhere. I still believe that medical school is a sack in which students are tossed for four years or less and then set loose for graduate (real) education which will turn them into competent doctors if they make the necessary effort. The final performance will depend on the qualities of the student rather than the formal education process they are forced to endure. The computer and the internet will be just another tool for self education.
Sir William Osler’s advice on how to learn medicine still holds. You must both read and see patients. No matter if you read a page or a screen.