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Medical education and the good doctor

“Ahhhhh” moans a 16-year-old girl, her face contorted in pain as she lies on a stretcher in a busy emergency room corridor. Her distress is elicited by gentle prods to her abdomen by a young surgeon summoned by the ER staff. Fever, recent vomiting, and discomfort in her lower belly have brought her here to the hospital. The surgeon’s hands move from the source of pain to the patient’s own hand and she says, “I am sorry for your discomfort, but I need to know more. I think you may have an inflammation of your appendix. I may have to operate to be sure and if I find that I am correct, I will have to take it out.” Twelve hours later, after receiving corroborative laboratory tests and diagnostic imaging results, an appendectomy is performed swiftly and without complication. In the recovery room, the surgeon briefly clasps the young girl’s hand once again and tells her that she should be back to her usual self in a few weeks.

The lifetime risk of acute appendicitis is approximately 5-10% and the simple story depicted above is played out many times each day around the world. As with any fiction, however, we may change the plot and so, the sense and implications of the story. For example:

The surgeon’s handsprodded roughly into the young girl’s tender belly and her moan became a scream.

and she saystestily to the ER nurse as she strides out of the room, “I want the urologist to see the patient; she likely has cystitis and I can see her again tomorrow if there is any problem.”

an appendectomy is performed. … During the procedure, the surgeon nicks a peri-appendiceal artery, resulting in significant blood loss necessitating transfusion.

We rely on physicians such as the young surgeon described above to correctly diagnose and effectively treat appendicitis, as well as the many other illnesses or traumas with which we may be afflicted. And we would like such care to be given in a professional manner with confidence and compassion. Knowledge, judgment, technical skill, and empathy are attributes most people would wish their doctor to have. The first three of these qualities clearly need to be learned; the last, although present in most people to some degree, is not always evident and can arguably be fostered in an appropriate environment and by mentorship. The ways by which students can—and should—be taught these attributes are numerous and have been debated by medical educators for over 200 years.

Knowledge, judgment, technical skill, and empathy are attributes most people would wish their doctor to have.

In the 19th century, lectures by an experienced surgeon or physician, either community-based or in a hospital setting, were a common way for the student to gain theoretical medical knowledge. Apprenticeships for these students would often involve following or accompanying these lectures as a means to gain clinical experience. Although such methods undoubtedly produced competent physicians (for the time), this was far from guaranteed: the teacher’s knowledge and background were not formally evaluated and they sometimes had little to offer as “experts” other than an interest in supplementing their income or increasing their prestige.

Abraham Flexner championed a significant change in this learning process in a 1910 report on the status of medical education in North America. His model, which became the most influential for medical student teaching in the 1900s, consisted of two years of basic science study—often with a heavy emphasis on lectures given by knowledgeable university faculty members—followed by two years of clinical study in the hospital setting. Flexner’s concept was widely adopted and is still used in its basic form by many universities today. Minor variations in Flexner’s scheme include introducing students to clinical topics—and patients—earlier than the third curriculum year, and inclusion of other subjects such as ethics, humanities, and medical professionalism.

More fundamental changes have been introduced in other models. Two of the most widely espoused are “problem-based learning” and “competency-based education.” The first of these, which gained significant popularity in the last part of the 20th century, emphasizes how to learn and how to find solutions to problems, rather than direct “learning,” such as in the lecture scenario. Such “self-directed” learning is facilitated by working with other students in small groups, and is often based on theoretical clinical scenarios.

More recently, the notion that learning (mastering) “competencies” related to specific objectives has become increasingly popular. Such competencies are predetermined by faculties or medical education institutions according to what is deemed important for the young physician to know upon graduation. They include competencies related to knowledge—such as the signs and symptoms of acute appendicitis—and techniques—such as how to perform a lumbar puncture.

Which of these, or other possible models, is the best to guide a medical student to become the competent and caring young surgeon whose patient encounter is outlined in the first paragraph? How does any one model apply to all of the many students with their varied educational backgrounds and underlying personalities? Which parts of the various models are worthwhile to keep and enhance, and which should be decreased in importance or eliminated altogether? The answers to these questions are certainly debatable and important to elucidate.

If the imaginary appendicitis scenario described above were to become real, it is likely that most of us would consider first our pain, then the treatment we are about to receive, and finally the manner in which this is explained and carried out. However, once the immediacy of the event is passed, we might reflect with benefit upon the ways in which our doctor came to be the person they are and how our medical schools can and should influence this.

Featured image credit: Doctor by marionbrun. CC0 via Pixabay.

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