Education at the Medical School

This year the Harvard Medical School undertook a major reevaluation of its curriculum. Dr. Alexander Leaf, chairman of the Med School's curriculum committee, headed the study. His report is now in the hands of Dr. Robert H. Ebert, Dean of the Medical School. The report will be released in the fall and members of the Med School Faculty will discuss its recommendations. In a speech delivered last winter, Dr. Ebert set forth his ideas on Medical School curricula and indicated the direction changes are likely to take. Excerpts of the speech are printed below.--Ed.

I.

The physician likes to view himself as an individual totally responsible for the care of his patients and a free agent in arriving at decisions. Individuality is important, and I shall return to it later, but the kind of individual responsibility which the physician assumes he has is shared with many others. For the facts are that medicine has become infinitely more complex, and no physician can provide all the benefits of modern medicine by himself. Like it or not, he is dependent upon others, and a laboratory error by a technician in a remote corner of the hospital may be as devastating to the patient's progress as an error in judgement on the part of the physician.

The modern physician . . . is annoyed if a patient asks about a recent medical advance reported in LIFE or TIME which he has not heard about, since he did not read LIFE or TIME first! He has little time to read, less time to reflect and almost no time to re-evaluate goals.

The complexity of medicine has had profound effects upon the practice of medicine. First, it has encouraged specialization by the physician, and according to the Coggeshall report the choice of over 88 per cent of new physicians is to enter specialized practice. The reason is obvious. It is far easier to encompass a special field of medicine than the totality of medical knowledge, and there is the opportunity to make an effort to keep up with advances in the field.

A second effect of the increased complexity of medicine is the centralization of many medical activities at or near the hospital. It is not that the beds are needed close by but rather that the elaborate diagnostic and therapeutic machinery of modern medicine has become hospital-centered.

A third effect is the impetus toward group practice. I use the term here not to describe a financial arrangement or even a formal or informal arrangement for referral, but rather to describe the fact that groups of doctors tend to cluster in hospitals, in clinics and in professional buildings, and they do so because their needs are interdependent. It is not that each is dependent upon the other, but rather that each needs certain common services--x-ray, laboraory, etc.

From the dawn of civilization those practicing the healing arts have met with frustrations, and the modern physician is no exception; it is only that the quality of his frustration has changed. The physician finds himself much in demand and he is torn between the exhaustion of overwork and the guilt of not fulfilling what he believes are all his obligations. He often works at a pace incompatible with home life, a life in the community apart from medicine or in fact any opportunity to enjoy the fruits of his labor. His anxieties which arise from this state of affairs are compounded by the feeling that he is not keeping up with medicine. a recent medical advance reported in Life or Time which he has not heard about, since he did not read Life or Time first! He has little time to read, less time to reflect and almost no time to re-evaluate his goals. Like all generalizations there are many exceptions, but the fact is that many doctors are overworked and have little time to keep up."

There are a variety of other frustrations but only one more I should like to mention. The modern physician is losing some of his identification with the community, not because of specialization or lack of interest, but because he is swept up in the inexorable force of urbanization which brings with it the kind of impersonal relationship brought into hideous focus by the refusal of certain New Yorkers to go to the aid of their fellow citizens being attacked by outlaws of the city. The physician too, if he is a product of the city, develops a certain indifference to the health problems of his community, although he may have the most intense interest in the welfare of his patients. This is not to say that every physician in rural America has a deep understanding of the health needs of his community. Nevertheless, he usually knows his community better than his urban counterpart and therefore is provided the opportunity to understand his patients better not just as sick people, but as members of a social group.

II.

Writing in 1924, Abraham Flexner in his book Medical Education, commented on the experience of most American medical students as follows: "They were grouped in fixed classes, the personnel of which was practically unchanged, except for outright losses due to failure, from year to year; they followed in fixed order, day by day, the same subjects, for the same length of time, in the same year and at the same hour . . . and, at regular intervals, all alike, in the same rigid groups, performed precisely the same practical exercises, attended the same quizzes and submitted to the same monthly, semi-annual and annual examinations. Anything more alien to the spirit of scientific or modern medicine or to University life could hardly be contrived."

It would be easy to assume that Flexner was describing medical education today rather than in 1924. Unfortunately, this book did not have the impact of his devastating critique of proprietary schools written in 1910.

Changes have been made in medical education since Flexner's time, although few schools have been able to escape the lockstep which he describes so vividly. But most medical schools continue to make certain basic assumptions which govern the teaching of medicine. The first assumption is that everyone should have essentially the same educational experience, regardless of interest, background, aptitude or ultimate choice of career within medicine. The second assumption is that some exposure to every held of medicine is desirable. It is universally accepted that it is impossible "to cover" all medical knowledge in medical school, but each specialty and each scientific discipline demands the students' attention during some part of the medical school experience. This might be called the "last chance" philosophy. If the student is not exposed to a speciality during medical school, he may never have the opportunity again. No one asks, "What difference would that make?" If he enters a branch of medicine in which the particular specially is irrelevant, he will not miss it, and if he needs the specially, he can learn about it later. The other argument used for requiring total exposure is that if the student is not required to take a particular specialty, how can he be recruited for the field.

The public wishes to have the practical general practitioner of the 18th and 19th centuries but endowed with all the knowledge and skills of the 20th century specialist. It wants the comfort of the home visit combined with all the diagnostic and therapeutic armamentarium of the modern hospital.

Harvard medical students are intelligent and critical, and yet in the past year they appear to have made two rather contradictory criticisms of the curriculum. Some students have

The modern physician. . . is annoyed if a patient asks about a recent medical advance reported in LIFE or TIME which he has not heard about, since he did not read LIFE or TIME first! He has little time to read, less time to reflect and almost no time to re-evaluate goals. complained that lectures were not well enough organized and failed to select out major facts and major concepts. Superficially it appears that Harvard students are simultaneously asking for more independence and more "spoon feeding." Yet these two requests are perhaps not as contradictory as they first appear, and both are a reflection of our approach to education. Perhaps what they are saying is this: If you insist on surveying every facet of medical knowledge, please give us some indication of what you as the faculty believe is important and what you consider unimportant. For if you do this and provide us with a little more time for study and reflection, perhaps we can participate in a more active ways in our own education. Or, as Flexner put it: "With certain obvious exceptions, the particular facts learned, the particular skills acquired, are of less importance than the habit of enquiry, the ability to use the senses, the capacity for well-directed effort."

While medical education as conducted by the medical schools has many weaknesses, it is at least the province of medical faculties and more and more it is being subjected to critical and often painful re-evaluation. The other half of medical education which takes place during internship, residency and fellowship is not the legal responsibility of the medical school or University and is more akin to the old apprenticeship system of education than the University. To be sure, University faculties are involved in University-affiliated hospitals, but the "curriculum" is the creature of the specialty boards, accreditation bodies and the pafrticular speciality groups within the hospitals. It is a system of education which has grown like Topsy, and interns and residents are more often conveted because of the service they provide than because the professional staff of a hospital has a deep concern for education. The hospital portion of medical education is enormously variable in quality. At its best it can provide a kind of experience more compatible with the concept of a University than the medical school experience. At its worst it is little better than a period of indentured service.

III.

In spite of the rigidity which the professions have built into the system of delivering medical care, change is occurring and will continue to occur at an accelerated rate. The impetus for change is from the public and the news media, the Government, and labor and management organizations are all instruments of this force. What the public wants of course is somewhat contradictory. It wishes to have the practical general practioner of the 18th and 19th centuries but endowed with all the knowledge and skills of the 20th century specialist. It wants the comfort of the home visit combined with all the diagnostic and therapeutic armamentarium of the modern hospital. And it wants all this for less money than it costs today.

It is not the purpose of this lecture to predict what the delivery of medical care will be like in the year 2000, but it will be quite different than it is today, and change will come about as the result of a variety of forces. The important point I should like to make is that medical education should prepare the student to cope with a changing world and to contribute in a thoughtful and objective way to the changing pattern of medical care.

A list of the qualities which should be fostered by a medical education--or at least preserved intact--are identical with those which the University seeks to develop.

1. The individuality of the physician should be preserved. As an educated man he sould be critical and willing to express his personal views and not simply parrot the party line of his professional group. It is curious that at a time when medicine is thought to be one of the few remaining vocations which emphasizes the importance of the individual that in fact the physican is firmly bound by the convention of his profession.

2. The educational process should preserve the joy of learning, for a lifetime of learning, for a lifetime of learning is ahead of the physician if he is to contribute effectively all his active life.

3. The education of the physician should encourage the assumption of responsibility. While this is an important quality for all our citizens, it has particular relevance for the physician, for he must be prepared to shoulder the responsibility for human life.

4. Finally initiative and imagination, or what might be called in combination, creativity, must be fostered. The quality of creativity can easily be destroyed by and educational process which is technical and unimaginative.

If these qualities are to be fostered, there are certain principles which must guide the planning of the educational process.

1. There must be a recognition of individual aptitude and individual differences. Quite different kinds of people can contribute to medicine, and it is reasonable to assume that they will learn different things at different rates. The rigid lockstep system of American medical education must be broken if individual aptitudes are to be fostered.

2. There must be time in the medical curriculum to pursue knowledge in some area of particular interest, for this is how the student will learn in the future. If he is so heavily burdened with required courses during his educational experience that there is no time for independent study, his continuing education will be is jeopardy. Experience in a research laboratory may or may not fulfil this need. If his work in the laboratory is essentially that of a technician, it will not.

3. Responsibility must be given the student first for a significant part of his own education and ultimately for the care of the patient, but the latter responsibility must be graded according to the student's ability to assume it.

4. Rather than one curriculum there should be several responsive to the different interests and backgrounds of students. We are educating men for a variety of careers, and our educational process must recognize this fact while protecting against the creation of trade schools turning out specialist technicians.

Medical education is a total process and the artificial division between medical school and internship and residency makes little sense. There must be the opportunity to plan in a rational way the total education of the physician.

Who will accomplish these reforms in medical education? There is no easy answer, but the University today is probably a more liberal force than the Colleges representing the specialties. It would be a progressive step if medical schools became more strongly identified with the University environment, for not only would this profit the student, but it might also allow a more objective look at the problems of medical care in this nation.Dr. ROBERT H. EBERT: 'Rather than one curriculum there should be several responsive to the different interests and backgrounds of students. We are educating mn for a variety of careers, and our educational process must recognize this fact while protecting against the creation of trade schools turning out specialist technicians.'