Great Health Care Requires Great Medical Educators

Education is not an industrial process; it is a human one.

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The quality of United States medical education is a matter of concern to every person in the country. In our nation of 315 million people, we log 1.3 billion doctor visits annually -- or an average of about 4 visits per person per year. If doctors are poorly educated, we stand to lose money, time, health, peace of mind, and in some cases, even our lives. If we do a good job of educating physicians, we reap substantial benefits, avoiding unnecessary care and harmful mistakes and enjoying longer, healthier lives.

About 60% of students who apply each year are not admitted, and many more students give up hopes of attending medical school before they ever apply. The more than 20,000 students who begin studies toward an M.D. degree each year in the U.S. have even greater investments ahead of them. Newly admitted medical students can expect to pay a small fortune over four years. The average cost of attending medical school at a public institution is about $50,000 per year, and this swells to $70,000 per year at private institutions. The typical public-school student graduates $150,000 in debt, while the figure is $180,000 for private school students.

SHARK300200.jpg"If I have seen further, it is by standing on the shoulders of giants." -Isaac Newton

(Library of Congress)

And medical school graduation is far from the end of training. To become fully qualified physicians and sit for a board exam, newly minted M.D.s must then complete residency training, which typically ranges from as few as three years (in fields such as family medicine and pediatrics) to as many as seven years (in fields such as neurosurgery). Many will then pursue additional fellowship training, for one to three years. Students who graduate from college at the age of 22 years with a goal of entering my field of pediatric radiology would typically complete medical school at 26 years, radiology residency at 31 years, and fellowship training at age 32.

An economist might add that there are substantial opportunity costs in pursuing this path. Instead of entering medical school, many of these students might pursue careers in business, in which, instead of paying out $50,000 per year, they might earn such an amount, if not more. As a result, many physicians-in-training postpone marriage and parenthood. By the time physicians complete their training, many of their college classmates already have homes, families, and established careers.

The major investments of time, talent, and treasure and the many personal and family sacrifices involved in becoming a doctor make it even more important to ensure that future physicians receive the best education possible. Traditionally, the 141 M.D. granting U.S. medical schools and their faculties have focused their attention on three key educational ingredients: curriculum, instructional methods, and assessment techniques. Curriculum concerns what knowledge and skills medical students are expected to learn, instructional methods address how they are taught, and assessment is used to determine how well they have learned it.

But there is much more to educating medical students than these three elements. A school can provide the perfect curriculum, state-of-the-art instructional methods, and unimpeachable testing, yet do a poor job of educating future physicians.

One ingredient missing from this account is the creativity, commitment, and inspiration of medical educators. Education is not an industrial process, akin to pressing mounds of clay into a uniform shape. Instead it is a human process. Students are not identical to one another. Each brings distinctive interests, abilities, and experiences. Like the practice of medicine itself, great education means establishing a relationship between human beings.

To promote excellence in medical education means paying attention to two different sorts of factors in the equation of educational excellence: those that tend to undermine the performance of medical educators, and those that tend to enhance it. One factor that detracts from educational performance is a lack of respect. Medical schools are financed largely by revenues from patient care, and schools are often ranked according to research funding. Despite the fact that the institutions themselves are known as schools, some may begin to see education as a loss.

This lack of respect for education can contribute to another problem, a dearth of resources. To educate future physicians, we need time, money, equipment, and personnel. If medical school faculty members become too busy caring for patients or doing research, they may not have time to teach. Because tuition revenues tend to be fixed, leaders may shift funding away from education to purposes that can generate additional revenue. Eventually, the size of teaching faculties may decline, at least relative to the number of students. Faced with such challenges, we need to remember that medical schools exist to educate physicians. All other responsibilities should flow from this.

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On the up side, there are several steps we can take to enhance the performance of medical educators. One is to make sure that educators remain engaged and challenged by their work. There has been a trend toward increasing centralization in US medical education, with a central authority determining what gets taught, how, when, where, why, and to whom. Here is the problem with that. Once educators become mere implementers of others' ideas, their level of engagement and growth diminishes. Education at its best more closely resembles a relationship (e.g. friendship) than assembly-line mass production. The personal commitment of educators is a vital

The moment medical educators stagnate, they begin to begin becoming disengaged and ineffective. Students can tell when an educator is just going through the motions, and it takes a huge toll on their enthusiasm. We need to keep educators engaged with students and excited about teaching by encouraging them to innovate and grow in their work. Great teaching is not a matter of knowledge transfer. Instead it involves a pursuit of knowledge shared by educators and students. Great educators don't merely tell students what to memorize; they engage their imaginations. They encourage learners to begin asking good questions, which is exactly what good doctors do.

Perhaps the greatest lure to excellence in medical education is the opportunity to see students flourish as medical professionals and human beings. It is deeply fulfilling to know that some bit of knowledge or skill an educator has promoted has enabled a student to make a positive difference in the life of a patient. It is even more so to see a former student thriving in the practice of medicine, making a real difference in the lives of patients every day fully and developing fully as a human being. Each medical educator is like a candle that has been set alight by the prior generation and has the opportunity to pass on the flame to the next, ideally burning a bit more brightly.

I had one particularly great medical educator who happened to be a Nobel laureate. But what made him great as a teacher was not captured by any of his accolades. It was to be found in the gleam that appeared in his eye and the quickening of his pace that occurred every time he or one of his students formulated a good question. In the words of one of his former students, no one came under his influence "without discovering in themselves unrecognized abilities and powers." In short, he didn't just teach facts, he taught learners to discover. He taught us to plumb the depths of our capabilities. A great educator, he helped to train many fine physicians who carry on his passion today.

When many of my colleagues and I look back on our own medical education, we are struck by how often the biggest difference was made not by curriculum or technique, but by the character and passion of a few great medical educators. These giants taught us not just facts and skills but how to interact with patients and colleagues, how to handle errors, how to balance the personal and professional dimensions of life in medicine, and how exhilarating it can be to feel that we contributed something important to a patient's life. The giants of medical education, like all great teachers, are benefactors of their students and communities, but they are also benefactors of mankind.