Learner-Centered Medical Education
http://www.100md.com
《新英格兰医药杂志》
Medical students occupy a curious position in the history of the American medical school. Before World War II, the education of medical students was the central mission of medical schools, and undergraduate medical education remains their one unique mission. Yet after World War II, as medical faculties expanded their activities in graduate-level teaching, research, and patient care, the education of medical students became no more than a byproduct of the operation of academic health centers.1
The diminishing visibility of the medical student is not in itself harmful for medical education, provided that faculties take students and teaching seriously. However, from the early 1900s to the present, there has been a persistent concern among medical educators that medical education has ceased to be an invigorating intellectual experience. During this time, a score of reports from foundations, educational bodies, and professional task forces have criticized curricula for rigidity, an excessive use of lectures, and an overemphasis on rote memorization.2 A century of curriculum reform has resulted in the introduction of new subjects, the elimination of antiquated ones, and the development of new instructional methods. However, medical education has a history of tinkering with the curriculum endlessly without realizing larger educational objectives. Schools have yet to create a true learner-centered environment that makes active, self-directed learning under the close tutelage of interested faculty members the core of the experience.
To medical educators, this lack of a learner-centered curriculum is cause for concern. Since the late 19th century, in addition to instilling high professional standards, medical education has been aimed primarily at helping medical students develop the power of critical reasoning, the capacity to generalize, the ability to acquire and evaluate information, and the intellectual tools to become lifelong learners. Accomplishing these goals requires thoughtful and personalized teaching. Instructors must generalize and synthesize, not just provide the view from their particular specialty. Students need seminars, tutorials, and individualized instruction, not lectures alone, for their reasoning powers to be developed fully. Students also need close interactions with experienced, mature physicians in the work of patient care — and the opportunity to talk with them about that work.3 Such a curriculum can be constructed only if a medical faculty sufficiently values teaching to take the time to do it well. Here, medical schools have typically fallen short of their potential.
A recent visit I made to a prominent medical school illustrates the low value placed on student affairs by contemporary medical schools. The instructor who once gave the most lectures in the physiology course had stopped teaching because he knew it was unimportant to his department chairperson. In many of the basic science departments, teaching laboratories had been converted into faculty research laboratories. In the department of medicine, with more than 300 full-time faculty members, the director of the third-year clerkship could not find enough professors to fill the 52 slots in the attending rotation schedule for the core medicine clerkship. He was lucky to find some stopgap solutions. A few years before, students had complained to the dean that they had insufficient contact with faculty. The school's response was to establish an annual faculty–student dance. Students told me that they did not object to a dance, but it did not substitute for the close personal contact and ongoing intellectual relationships with faculty that they had been seeking.
Educational outcomes are notoriously difficult to measure. There have been no controlled studies documenting the superiority of a learner-centered curriculum. Nevertheless, it is difficult to imagine how an environment in which students' intellectual needs are not a central concern can be good for the education of a physician, in terms of either the development of critical intellectual skills or the internalization of professional values and attitudes. The time-honored wisdom in medical education (which has been reinforced by studies in educational psychology) is that meaningful, ongoing relationships between faculty and students are essential for the development of true professionals. Quoting John Henry Newman, William Osler wrote, "An academical system without the personal influence of teachers upon pupils, is an Arctic winter."4 Our failure to create an educational environment in which such an influence flourishes suggests that we are not doing all we might to produce competent, caring physicians.
How did this situation arise? Good teaching is time-consuming and labor-intensive. It encroaches on the time faculty members can spend on research and patient care. In most U.S. medical schools, faculty members are rewarded with promotions, higher salaries, or both for financial "productivity" in research and, more recently, patient care. Similar incentives to promote and reward good teaching are seldom found. Given that human beings respond to incentives, it is hardly a surprise that medical faculties pursue research and patient care to the relative neglect of teaching. Good teaching, of course, still occurs widely in U.S. medical schools, but by chance rather than by design. The system is not structured in a way that would encourage or reward it.1
Academic administrators frequently note the financial obstacles to creating an institutional focus on the education of medical students. Research and patient care, they point out, generate revenues, whereas education does not. They would gladly do more to promote effective teaching, they say, if only they had the funds to do so.
Though medical education is not inexpensive, academic leaders often ignore the fact that the funds to support it properly are already available, if they choose to use the funds for this purpose. Student tuition, appropriations from state legislatures to public schools, and certain portions of endowment income have always been intended for the education of medical students. Traditionally, deans have appropriated these funds for purposes not directly related to education — an animal care facility here, the establishment of a new research program there. Academic leaders bemoan the lack of funds to support faculty teaching time, even as they spend tens of millions of dollars to build new "teaching and learning centers" or expand the administrative bureaucracy.
Ultimately, the greatest challenge to achieving learner-centered medical education involves attitudes, values, and priorities — not a lack of money. The deeply ingrained subordination of teaching to research and patient care overshadows all other obstacles to establishing a student-oriented curriculum. Yet the situation is far from hopeless, for institutional values may be changed. For change to occur, teaching-oriented faculty members must demand loudly, publicly, and repeatedly that medical schools use more of their resources directly for medical education. Deans must pay teachers for their time and promote those who are meritorious. Philanthropists can help by specifying that their gifts be used to support teaching and learning rather than research or patient care. Schools that succeed are likely to become models for others, just as the Johns Hopkins Medical School did a century ago. Thus, we have an opportunity to serve the needs of learners, not just those of faculty members and institutional coffers, as we plan the course of medical education in the 21st century.
Source Information
From the Department of Medicine, Washington University School of Medicine, St. Louis.
References
Ludmerer KM. Time to heal: American medical education from the turn of the century to the era of managed care. Oxford, England: Oxford University Press, 1999.
Christakis NA. The similarity and frequency of proposals to reform US medical education: constant concerns. JAMA 1995;274:706-711.
Ludmerer KM. Learning to heal: the development of American medical education. New York: Basic Books, 1985.
Teacher and student. In: Osler W. Aequanimitas: with other addresses to medical students, nurses and practitioners of medicine. 3rd ed. Philadelphia: Blakiston, 1932:26.(Kenneth M. Ludmerer, M.D.)
The diminishing visibility of the medical student is not in itself harmful for medical education, provided that faculties take students and teaching seriously. However, from the early 1900s to the present, there has been a persistent concern among medical educators that medical education has ceased to be an invigorating intellectual experience. During this time, a score of reports from foundations, educational bodies, and professional task forces have criticized curricula for rigidity, an excessive use of lectures, and an overemphasis on rote memorization.2 A century of curriculum reform has resulted in the introduction of new subjects, the elimination of antiquated ones, and the development of new instructional methods. However, medical education has a history of tinkering with the curriculum endlessly without realizing larger educational objectives. Schools have yet to create a true learner-centered environment that makes active, self-directed learning under the close tutelage of interested faculty members the core of the experience.
To medical educators, this lack of a learner-centered curriculum is cause for concern. Since the late 19th century, in addition to instilling high professional standards, medical education has been aimed primarily at helping medical students develop the power of critical reasoning, the capacity to generalize, the ability to acquire and evaluate information, and the intellectual tools to become lifelong learners. Accomplishing these goals requires thoughtful and personalized teaching. Instructors must generalize and synthesize, not just provide the view from their particular specialty. Students need seminars, tutorials, and individualized instruction, not lectures alone, for their reasoning powers to be developed fully. Students also need close interactions with experienced, mature physicians in the work of patient care — and the opportunity to talk with them about that work.3 Such a curriculum can be constructed only if a medical faculty sufficiently values teaching to take the time to do it well. Here, medical schools have typically fallen short of their potential.
A recent visit I made to a prominent medical school illustrates the low value placed on student affairs by contemporary medical schools. The instructor who once gave the most lectures in the physiology course had stopped teaching because he knew it was unimportant to his department chairperson. In many of the basic science departments, teaching laboratories had been converted into faculty research laboratories. In the department of medicine, with more than 300 full-time faculty members, the director of the third-year clerkship could not find enough professors to fill the 52 slots in the attending rotation schedule for the core medicine clerkship. He was lucky to find some stopgap solutions. A few years before, students had complained to the dean that they had insufficient contact with faculty. The school's response was to establish an annual faculty–student dance. Students told me that they did not object to a dance, but it did not substitute for the close personal contact and ongoing intellectual relationships with faculty that they had been seeking.
Educational outcomes are notoriously difficult to measure. There have been no controlled studies documenting the superiority of a learner-centered curriculum. Nevertheless, it is difficult to imagine how an environment in which students' intellectual needs are not a central concern can be good for the education of a physician, in terms of either the development of critical intellectual skills or the internalization of professional values and attitudes. The time-honored wisdom in medical education (which has been reinforced by studies in educational psychology) is that meaningful, ongoing relationships between faculty and students are essential for the development of true professionals. Quoting John Henry Newman, William Osler wrote, "An academical system without the personal influence of teachers upon pupils, is an Arctic winter."4 Our failure to create an educational environment in which such an influence flourishes suggests that we are not doing all we might to produce competent, caring physicians.
How did this situation arise? Good teaching is time-consuming and labor-intensive. It encroaches on the time faculty members can spend on research and patient care. In most U.S. medical schools, faculty members are rewarded with promotions, higher salaries, or both for financial "productivity" in research and, more recently, patient care. Similar incentives to promote and reward good teaching are seldom found. Given that human beings respond to incentives, it is hardly a surprise that medical faculties pursue research and patient care to the relative neglect of teaching. Good teaching, of course, still occurs widely in U.S. medical schools, but by chance rather than by design. The system is not structured in a way that would encourage or reward it.1
Academic administrators frequently note the financial obstacles to creating an institutional focus on the education of medical students. Research and patient care, they point out, generate revenues, whereas education does not. They would gladly do more to promote effective teaching, they say, if only they had the funds to do so.
Though medical education is not inexpensive, academic leaders often ignore the fact that the funds to support it properly are already available, if they choose to use the funds for this purpose. Student tuition, appropriations from state legislatures to public schools, and certain portions of endowment income have always been intended for the education of medical students. Traditionally, deans have appropriated these funds for purposes not directly related to education — an animal care facility here, the establishment of a new research program there. Academic leaders bemoan the lack of funds to support faculty teaching time, even as they spend tens of millions of dollars to build new "teaching and learning centers" or expand the administrative bureaucracy.
Ultimately, the greatest challenge to achieving learner-centered medical education involves attitudes, values, and priorities — not a lack of money. The deeply ingrained subordination of teaching to research and patient care overshadows all other obstacles to establishing a student-oriented curriculum. Yet the situation is far from hopeless, for institutional values may be changed. For change to occur, teaching-oriented faculty members must demand loudly, publicly, and repeatedly that medical schools use more of their resources directly for medical education. Deans must pay teachers for their time and promote those who are meritorious. Philanthropists can help by specifying that their gifts be used to support teaching and learning rather than research or patient care. Schools that succeed are likely to become models for others, just as the Johns Hopkins Medical School did a century ago. Thus, we have an opportunity to serve the needs of learners, not just those of faculty members and institutional coffers, as we plan the course of medical education in the 21st century.
Source Information
From the Department of Medicine, Washington University School of Medicine, St. Louis.
References
Ludmerer KM. Time to heal: American medical education from the turn of the century to the era of managed care. Oxford, England: Oxford University Press, 1999.
Christakis NA. The similarity and frequency of proposals to reform US medical education: constant concerns. JAMA 1995;274:706-711.
Ludmerer KM. Learning to heal: the development of American medical education. New York: Basic Books, 1985.
Teacher and student. In: Osler W. Aequanimitas: with other addresses to medical students, nurses and practitioners of medicine. 3rd ed. Philadelphia: Blakiston, 1932:26.(Kenneth M. Ludmerer, M.D.)