Ronald A. Arky, MD.
New England Journal of Medicine
May 4, 2006, Vol. 354, Issue #18, pg. 1922-1926.
Review by: Hershey Bell, MD <hbell@lecom.edu>
Summarizing the history of the Shattuck Lecture relative to medical education, Arky notes that the 1904 lecture delivered by general practitioner George Summer Huntington (of Huntington’s chorea fame) spoke on the “Relation of Comparative Anatomy to Medical Education and Practice”. James Faulkner, Dean of Boston University’s School of Medicine, in the 1954 Shattuck Lecture, discussed the reform of the medical school curriculum and the schism between the basic science and clinical faculties. He feared that the rising cost of medical education would change the composition of medical school classes. In 1967, John Millis, the first non-physician to deliver a Shattuck Lecture, used his role as chair of the Citizen’s Commission on Graduate Medical Education to elaborate on the “large and perplexing problems” besetting graduate medical education in the United States. He specifically commented on the “severity of discontinuities” in medical education.
Tracing the history of modern medical education, Arky notes that the Carnegie Foundation’s review of college education in the United States led to the historic 1910 Flexner report which sought to diminish variation in medical education in the United States and Canada. Among the reforms brought about by the Flexner report were the demise of profit-making schools, strengthened ties between medical schools and universities, incorporation of laboratory sciences into the curriculum, and early contact between medical students and patients.
Arky reflects on his 40 years in medical education as it relates to the consequences of the Flexnerian revolution. He summarizes his observations with the statement, “The dichotomy between advances in the biological sciences and their effects on diseases, on the one hand, and lack of progress in medical education, on the other hand, is striking.
In the section, “Medical Education as a Science”, he comments on Malcolm Knowles contribution regarding adult learning (andragogy) versus pedagogy. He then comments of the contributions of Eric Kandel at Columbia University. His research, involving a series of ingenious studies of the neural circuits of the giant marine snail aplysia, has clarified a molecular basis for memory which provides new insights into the molecular mechanisms of learning. Kandel’s research has opened the pathway toward an understanding of the physiology and pathophysiology of learning.
Arky’s reflection on his past 18 years teaching medical students includes “a number of surprises related to learning disorders.” These include the connection between the manifestations of dyslexia and attention disorders with the stresses of clinical rotations and board examinations, and most strikingly, “the small group of students who have earned such kudos as Rhodes Scholarships, election to honor societies, and the highest awards for undergraduate studies yet who have difficulty taking standardized exams.” These students appear to lack the ability to “integrate and apply their knowledge in the highly structured environment of complex multiple-choice examinations.”
He comments that “it has often been said that all doctors are teachers, since the word ‘doctor’ comes from the Latin root for ‘teacher’.” Coupled with the notion of “see one, do one, teach one”, this leads to the false implication that teaching is a simple task. He calls this assumption “nonsense”. Medical science has been slow to recognize medical teaching as a specialty.
He notes that medical education is disjointed with tenuous links from undergraduate to postgraduate education. He comments that “although undergraduate programs are slowly embracing the concept of competencies ... the link between the two phases of education is still weak and theoretical.” Among the elements downplayed are professional development, lifelong learning, reflection, and the evaluation of attitudes and communication.
Arky expands on Faulkner’s 1954 observations about the “schism between the faculties in the basic sciences and the clinical disciplines”. He believes the schism persists and may be responsible for the “serious disjunction – that experienced by medical students making the transition from the preclinical realm to the clinical world.” He equates this to taking “students who are still ... on training wheels” and placing them on “a busy expressway.” He believes part of the issue lies with the stagnation in the reformation of clinical clerkships over the past 50 years.
He describes an effort at Cambridge Health Alliance whose curriculum incorporates medicine, surgery, pediatrics, obstetrics, radiology and neurology and “ensures medical students contact with experienced clinical mentors and advisors.” The effort is designed to formalize clinical instruction – “an experiment in which the best and most appropriate methods for the clinical education of medical students are being tested.”
He reinforces the patient-centered principle that “the ultimate goal of medical education is to ensure that students can be transformed into the most effective deliverers of patient care that is possible.” He says it must “transcend enabling students and physicians to achieve passing scores on board examinations, meet licensure requirements, or attain recertification.” He believes we must build effective feedback loops derived from clinical reviews and the design of the medical curriculum. When root causes of medical error are discovered, this must translate into reform in the undergraduate, postgraduate and continuing medical education curricula.
He calls for an evidence-based approach to medical education. “The goal should be to tailor the information to the individual ... and to build in methods of assessment of ... knowledge base, performance, and efficiency.”
He concludes by pointing out that continuing medical education “is in trouble” in that physicians only prescribe appropriately in about 50% of cases. Another study suggests that greater clinical experience correlates with an inferior quality of care. He then points out the concerns about the linkage between pharma and CME. Relative to CME, he believes we are in need of “another Flexner or Carnegie.
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