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Teaching Medicine

One must think, and probably agree, that there have been many changes in the teaching of medicine, throughout the decades up to the present time. However there might be debate as to how efficient the changes have been, or how necessary some changes have been. Keeping in mind, obviously, that ultimately it is the patient who is the final concern.

If we break down the teaching of medicine, we can reduce it to three broad categories of responsibilities and concern:

  • One is the clinical information itself. This includes the discovering and identifying of disorders and diseases, the evolving applicable instrumentation and its proper use, and the diagnosing, treating and the evaluation of treatments.
  • The second responsibility is the delivery or presentation of this information. For example the teachers and their individual personalities, their comfort zones in disseminating information, and the broad spectrum of evolving, appropriate technology, such as classroom electronics and online deliveries.
  • The third is the target market (meaning the student) to whom the information is delivered.

The question we should be asking is, "are we as efficiently concerned with changes in the ‘market’ as we have been with changes in the other two elements of medical education?”

Granted, from the earliest recorded medicine and the teaching of it, perhaps as far back as the 2nd millennium B.C. until today, there have been changes in medicine. Therefore, there had to be someone to learn from someone who knew and could teach, as well as someone to decide what to teach. The chances are that quite frequently these responsibilities were the responsibility of one individual (e.g. the teacher who knew the information and decided how to present it). The overall approach to teaching medicine has gone through change merely by evolving into the more "democratic” system of today as opposed to the ancient, more traditional, master-apprentice paradigm of clinical medical training. Obviously, the mere numbers of students and available professors has dictated the need to stray from the older traditional education that began with ancient one-on-one education.

When considering changes in clinical information, some profound discoveries have revolutionized our knowledge base of medicine. Some that come to mind are; a) Harvey’s direct observations via dissection and his uncovering of the role of a closed circulatory system, with capillaries being the sites of exchanges, b) the identifying and studying of something called "cancer,” c) Freud’s opening up of the mind, d) the value of Crawford Long’s application of diethyl ether, e) the profound value of the sterilization of objects or food, f) the "genetic revolution” and g) the development of an absorbable suture and its effect on surgery. Every time a disease is identified, its pathophysiology worked out, and the treatment protocol discovered, a bell rings and medical schools are globally alerted to another inclusion in their training regimens. Obviously there are a myriad of innovations related to increasing our clinical information. The big question is, "just how much can the curriculum bear?” At times, decisions have to made involving what, if anything, should be discontinued so that new information, if necessary, can be added.

So do we see changes in clinical information? The answer, "Yes, constantly.” Is it important enough to implement changes in medical education? Usually yes.

With regard to delivery or presentation in medical training, have we had to go through some changes? Of course we have. Probably one of the most dramatic concerns historically, was the issue of acquiring cadavers (bodies) for educational needs. From the "creating” of the bodies (e.g. evidence of actually killing to "create” the bodies), to "grave robbing,” to whole body and body parts donations, to the purchasing of bodies from underdeveloped countries, to the more contemporary, technically creating mechanical simulations or computerized facsimiles of bodies or body parts. There has been an evolution in the classroom. From the traditional, original straight lecture during which the professor "merely talked” to the class, to the use of creative classroom aids (e.g. paper handouts, first mimeographed, then Xeroxed, etc.) to the modern more technical instrumentation (e.g. computer graphics, power points, on-line texts and references). We have ushered in the electronic age in terms of the delivery or presentation of information. Issues such as "cost effectiveness”, "reaching out to more with less, faster”, "increasing student independence”, have become major concerns in our delivery of information. Debates as to effectiveness have almost become akin to debates on economy, where we might have Nobel laureates voicing opinions from completely opposite perspectives. This leaves Mr. or Ms. Average in a quandary as to which direction to lean (or which opinion to believe).. We see studies or research suggesting one way to present information while other reliable investigations make opposite claims. Much like in the "era” of the "self-programming” texts a number of years back, we are constantly trying to develop a formula with which we could deliver information to the broadest array of personalities displaying the widest spectrum of learning styles, and often within the specific constraints of four walls. We have even developed the necessary techniques and machinery to deliver the same information over a wide geographic area, and often without sight of the student. By the way, in our quest to bring about "necessary” changes in our delivery and presentation of information, we should not forget an important element of any good classroom presentation. That is the comfort zone of the individual who is making the presentation. No matter what technical "aids” we may provide for that person, if the professor’s comfort zone is interfered with or not accommodated for, there is a good chance that the delivery of the information will be ineffective.

So are we involved in changing the way(s) in which we deliver information? We certainly are. Constant self evaluation of teaching methods, especially in light of (seemingly endless) changes in technology, are typical of good institutions.

And now to consider the "market” of our efforts. As defined earlier "market’ refers not only to the health care needs of the population that indeed may be changing, but rather on the health care practitioner applicant pool.

Are we getting so engrossed in the important concerns of "information ballooning” and "delivery logistics” that we may not be paying enough attention to the "changing student”? We can reasonably assume that in the earliest days (certainly the BCE or BC days, and for some length of time through the early AD days) of medical education, there was almost a personal element involved in attracting and then teaching the medical student. With the one-on-one tutorial system that was so common, both the appeal and enticement of the medical applicant as well as the learning environment for the medical student were based on a personal relationship with the "healer”. Most probably during the times of Abraham, Ramses, Caesar, Gautama Buddha, BCE or even up to the early recordings of universities or formal schools during the 10th through 13th centuries AD, in order for one to become a medical student, a personal acceptance from an established "healer” had to be sought and secured. Eventually more formal and standardized criteria evolved in order for one to become a medical student. Although schools around the world might have been somewhat diverse, the criteria for acceptance into medical training probably had (and most likely still has) some broad commonalities. Some of the influences on the acceptance into a medical training program at one time or another have probably included gender, age, geographical origin, political support, economics, a personal statement that could offer insight to one’s philosophy or values, and / or some level of prior education. In the more modern times we have added some form of standardized testing such as the MCAT exam. Add to these criteria the value of the "interview”. For decades these criteria seemed to be appropriate because the medical community felt that the results have been successful. We indeed have been accepting the "right” candidates, and we indeed have been turning out the desired practitioners.

However, if we take a look at some of the turns that our present system of education has been and is now taking, from early childhood education on up, can or should we continue to rely on the same criteria for selection? For example family pressures and influences often supersede the school guidance with regard to which courses should be taken and when. All to "improve” the presentation of the transcript, regardless of the student’s desires or skill levels.

Are there changes taking place in the relationship between family values and education that could be producing a different applicant? For example the family drives to pressure the youngster or the school to add particular extra-curricular involvements at school so that the resume or transcript coming out of secondary or even undergraduate school becomes more "acceptable”, regardless of the interests or involvement of the student.

Are there changes taking place in the development of the personality, from early childhood on, that might be resulting in a different candidate for medical training? For example, the increasing needs to find the information faster and with less intense effort. Add to this, the developing assumption that there are certain entitlements that the student is possibly being conditioned to expect. Are students applying to medical schools today, with the same senses of responsibility and levels of maturity that we saw in the past?

Are there changes taking place in the grading policies at the secondary as well as the undergraduate collegiate level that are making or will make it more difficult to include as comparative evaluative tools when screening applicants? If so, are students becoming more aware of these policies and incorporating them in expectations that they formulate?

We probably can justifiably assume that students today are as intelligent and capable as they were when Abraham’s physician agreed to tutor one, or when a candidate was selected to enter into medical training at Padua in the 1500s, or when Jackson Memorial Hospital’s School of Nursing accepted an applicant sixty years ago. But with the changes in behavioral and societal values and influences that we are now recognizing, shouldn’t we ask if our evaluative and screening protocols should also be reflective of these changes.

In other words has the "market” (applicant pool) to medical training changed? It certainly seems as if it has. If so, are we giving as much credence and attention to how we should go about measuring whether or not an applicant should be accepted and would be successful in "the program”? Are we as sensitive to these changes in the applicant pool as we are to changes in the curriculum and the presentations of the curriculum?

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