An immodest proposal for medical education

Right at the very beginning of their studies, medical students have strong ideas about what kind of doctor they want to be, even if they know very little about how to actually be a doctor. In one study medical students regarded empathy, motivation to be a doctor, good verbal communication, being ethically sound and honesty as the most important qualities. Medical education needs to be radically reformed if it is to support these ideals which are too easily lost.

Educationalist, Sir Ken Robinson interviewed on radio 4 last week, was asked whether he thought it necessary to master basic skills in literacy or numeracy before giving expression to language or mathematics. He responded,

“Well it’s wrong … it’s just not true. It is important that you learn these things as you go on , but this is a matter of pedagogy. I mean for example, we’re here in Liverpool, this was the birthplace of the Beatles. When they started out they knew about three chords but they had fantastic energy, compassion, enthusiasm for music. Well, nobody would deny that they became much more sophisticated musicians as they went on, but they were impelled to become more sophisticated by their passion for the music they were creating.”

He continues to say that great teachers give students a passion for their subject and their enthusiasm for learning follows from that. We need to give medical students a passion for the practice of medicine right from the first day they start medical school.

I’ll acknowledge here, that increasing numbers of medical schools have introduced patient-contact in the first year. But it needs to go much further.

The entire first year of medical school should be vocational.  Students should spend the whole year seeing how medicine is practised from the perspectives of different types of doctors, allied health professionals, managers, policy makers and most important of all, patients. They need to know what it’s like to live with a chronic disease and deal with doctors and the health and social care systems in which they will one-day work. They should learn about what it means to be a professional, about the privileges, responsibilities and stresses of their profession. They should learn from close observation and role models about the responsible use and irresponsible abuse of power. A grounding in narrative medicine and the medical humanities will be essential for them to develop the ability to critically balance such a wide range of perspectives.

They should learn about medicine’s historical, social and political roots, the role of advocacy and the importance of global health, public health and the social determinants of health.

To make sense of this they will need plenty of opportunities to meet with their peers and more experienced mentors to see how their experiences fit with their preconceptions and their ideals. This is how most medical education should happen, especially if we want our students to understand the complexity of clinical practice. These groups would be ideal fora for discussing the contested grounds of professional behaviour and medical ethics and learning about the value of narratives, the skills of peer supervision and the ability to reflect.

At the end of this year, they should be asked a question,

Which of you still wants to be a doctor?

If the experiences are sufficiently rich, both wide-ranging and deeply considered then there will be a minority who have discovered that medicine is not at all what they had expected (or it is as bad as they had feared, but had hoped it was not) and they will have the opportunity to change career before investing several more years of their life and money.

Those that remain will be much clearer than most medical students are at present, about what it means to be a professional, why medicine matters and what matters to patients.

And when they then start their basic medical sciences their ideals will be rooted in an ethically informed professional identity, a much clearer idea of their heritage and their future.

And, one would hope, their learning will be impelled by their passion.