A change in teachers is less likely. Clinical teaching posts have status attached to them; a private man likes to be able to say he "spends some time with the students." At the same time, teaching hasn't got much value as a way to be promoted within the academic hierarchy; medicine, like every other field, puts its emphasis on published research. This leads to a multitude of rather casual teachers who may spend only a few hours a year with the students. These people-like the diabetes expert, who comes to the hospital once every three months to deliver his little talk-are most pernicious. They do not care enough about teaching to attempt to do it well; they don't have enough experience with students to know how to direct their talk; they have never received any training in exposition and attach no significance to a good delivery.
Having dismissed these people, one should say that medicine does indeed correctly sense that private, experienced practitioners have accumulated practical knowledge that ought to be communicated to students. Unfortunately, this is not the way to do it.
Methods of teaching require considerable revision. You can be assured that this is taking place-it is always taking place and always has been. Curricula change, new courses spring up and others die, grand lectures on education are given citing Gushing and Osier, but somehow the fundamental quality of medical education remains the same.
The methodology continues to be perplexing. The notion that the subject should be suited to the manner of teaching; the idea that certain things are best taught in lectures, others in seminars, others individually; the understanding of those qualities that distinguish the lecture from the slide from the
printed page from the visceral experience-all these things are traditionally lacking in medicine.
Future medical educators, for example, will probably look back on the teaching hospital and shake their heads at the way "patient material" was used. One can argue that this use, at the present time, is highly inefficient. The individual patient in a teaching hospital is not intensively used for teaching. A bizarre case may be seen by fifty or sixty people, but the average ward patient is seen by many fewer, particularly if his problem is common and his stay in the hospital is short.
The need to see patients firsthand is an important part of medical education; one must have experience with many ill individuals, exhibiting many different manifestations of disease. This is necessary because there are both many diseases, and many forms that a disease will take in different people. To obtain the proper depth and breadth of experience requires a long time; a student or house officer must remain in the hospital at all hours for many years. Otherwise, he is going to miss vital experiences.
However, a number of ways of "saving the patient for future reference" are now possible. Teaching collections of X rays have existed for several years, enabling students to gain broad radiological experience without waiting for the patients actually to come in. But this is only the beginning: one can record a patient's appearance and important physical findings on video tape; one can even record an interview and history-taking. By such techniques literally hundreds of students can, over a period of years, have some experience with a given p;
And one can go further. For example, one n most severe limitations of modern clinical tea is that the student cannot really use the pati«"practice on." While mistakes are an imp* part in any learning process, in the hospita are discouraged and guarded against-and n so.
What is needed, of course, is a disposable tient, for whom mistakes do not matter. In the one can argue, the disposable patient was pro by society in the form of the charity case (at this was the popular belief); but this requiu can now be provided by technology. Anesti have developed a lifelike plastic dummy i for students to practice on; this dummy can allergic reactions to anesthesia, cardiac and n atory arrests, and a variety of other serious ci cations. The student can practice on the di«with impunity. So far, the only analogous sin is that provided by the post-mortem patient used for practice of surgical procedure. B» will see much more in the future.
For example, a teaching program can be pii a computer, enabling the student to ask ttu tient" questions, and get back replies. On th-. of such an interview, the student can make a nosis and institute therapy. The computer car inform the student of the consequences of hi scribed regimen.
In fact, such methods are already in usual Board Examinations, Part III-the section to interns prior to certification. The exam imong other things, film clips of patullowed by questions about the patient's It also contains a most interesting section if brief histories, followed by specific such as "What would you do immedi- iiis patient?" After each question is a :ssible answers, such as "Begin intrave- :eplacement," "Start antibiotics," "Give iid so on. And following each answer is 'lit space.
nt selects the therapy he wants and er- acked-out space to reveal the conse- his choice. If he has chosen correctly, i will be encouraging: "Patient im- Hut if he is wrong, the answer is likely to Patient dies."
se techniques, it is possible to give the posure to rare clinical situations he r see otherwise. It is also possible to ulent exposure in depth to a problem. iiki program the differing clinical histories patients with hyperthyroidism, for ex-let the student work through them all, idea of the differences from case to nt this will ever replace experience at the it it will certainly supplement that and very soon. There are two reasons L-chniques will gain rapid acceptance.
is a slowly simmering rebellion against the length of medical education. In this country the average physician is almost halfway to the grave before he is prepared to start practice-and the trend is toward even longer educational periods, not shorter ones. At the same time, there is a demand for more physicians, and the suggestion that this demand can be met, in part, by faster education. There is also a growing suspicion that in affluent America some of the best young men shun medicine because the educational period is so long.
As an educational process, medicine has suffered the full effects of the scientific outpouring of information; the response of medical educators has been simplistic-to lengthen the period of formal training as the body of knowledge has increased. This cannot go on indefinitely, and specialization-breaking up knowledge into smaller and smaller areas-will not provide the whole solution.
As a stopgap measure, medical schools have kept the total number of years constant, but have lengthened the per-week teaching load. Thus medical students at Harvard attend twice as many hours of classes per week as law or business students. Of necessity, this makes medical education a very passive business and deprives the student of the single most important thing he desperately needs to learn while at school-how to initiate the educational process for himself, later on, when he is a practitioner.
For medical schools there are only two solutions: to teach less or to teach more efficiently.
Medicine has been reluctant-sometimes wisely, sometimes not-to teach less. Curriculum changes are a traditional sport, but they occur slowly (John Foster notes that "it is easier to move a graveyard than to change a medical curriculum") and never seem to make manageable the total information to be mastered. The current administrative structure of medical schools appears incapable of curtailing the curriculum. Educators must therefore devise ways to teach faster. It is the only solution.