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Thoughts on Reforms in Preclinical Medical Education

By Rich Joseph

In a recent report  by the American Association of Medical College’s (AAMC) on the “Learning Objectives for Medical Education,” there is a clear description of the professional ideals that physicians in training are expected to develop during their time in medical school.  Lest we forget, let’s take a moment to review these guiding principles.  Physicians must be “altruistic,” “compassionate and emphathetic,” “ethical,” “knowledgeable,” “skillful,” and “dutiful.” I hope you would agree that not only are these are qualities admirable, they are essential for providing excellent patient care. For many of us, the unique opportunity to build and embody these ideals is the reason we entered the medical profession.


These ideals are designed to provide a framework upon which to build our knowledge, clinical skills, and all of the hard learned experiences that make us better doctors. Without this framework, the whole edifice of our professional development is at risk of collapse. We end up working ourselves into the ground without a clear vision of what we are working towards, who we are working for, and how our efforts tie into the evolution of medicine and health care more broadly. We end up accelerating our own demise, the so-called “burnout” phenomenon.  But most of all, we end up losing ourselves in a system is often antagonistic to these ideals. I imagine that it is easy to feel lost and helpless—a cog in a wheel that keeps turning until you finally acquiesce and roll with it. It must be frustrating to envision the physician that you aspired to be, and to watch that vision fade as you relent to the powers that be.  I’m sure that many of you see this happening every day, and even from my vantage point, way down at the bottom of the totem pole, I see it too and I fear for my future self.


How does this happen? How are the ideals that we hope to embody as physicians gradually eroded by the health care system? Clearly, there must be some grave misalignments between ideals and realities. From my perspective, I cannot yet speak to the personal changes that occur when one enters the clinical phase of medical training. However, I would argue that this erosion process begins even earlier, in the preclinical years.  After being lectured at for hours on end, day in and day out, it is hard not to feel a tad less human, and bit more like a robot. Your memory is jam packed with a new language strung together in a series of random facts, facts condensed to buzz words, and buzz works morphed into pneumonics to the point that you forget which pneumonic applies to which topic. After spending 8 plus hours each day with your head in a book and in front of a screen, the very act of interacting with another human being becomes a bit more daunting and uncomfortable. Preclinical medical education is so machinelike that by the end, all you can wish is for a few more gigabytes of storage space in your brain.    


Thankfully, preclinical medical education is on the cusp of reform, and I believe this is for the better. In a recent article in the New England Journal of Medicine, Charles Prober, MD and Senior Associate Dean of Stanford School of Medicine, joined forces with Chip Heath, Ph.D. and Professor of Organizational Behavior at Stanford’s Graduate School of Business, to usher in a new paradigm for medical education.  In this proposal for reform in medical education, the authors champion the “flipped classroom model” in which students learn the necessary medical science through online, module-based tutorials. After an introduction to the facts, the facts are solidified by shrouding them in a clinical context with realistic cases, peer interaction and team-based collaboration, and early clinical exposure. In essence, the key is to make the facts “stickier” by making them more human. After all, isn’t this what medicine is all about in the first place?


Ultimately, Prober and Heath are clamoring for a way to “make better use of our student’s time” by delivering the information as efficiently as possible. This seems quite feasible. Given the innumerable educational resources available to students these days, it is possible for a diligent and disciplined team of clinicians, educators, and tech entrepreneurs to develop a standard medical curriculum that delivers only the essentials on an interactive, user-friendly platform. Given the trends toward open source education, it is only a matter of time before this happens and medical students across the country are learning from one standardized, online, modular curriculum that combines material from the best lecturers at different schools. When this happens, what is going to differentiate one medical school from the next? Will it even be necessary to attend a physical medical school in the first place? More free time is great, but it is how you use that time that counts. The medical school of the 21st century will be that which uses this free time to better cultivate those time-tested ideals such that they may persist amidst the countercurrents of the system, and ultimately triumph to change health care for the better. 

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