Make lectures in medicine compulsory?

We have been having a debate on whether lecture attendance in medical school should be compulsory. Personally, I am horrified by the idea. But others have different views. The debate is over at edmeded, but below I post what I wrote, but with some links and quotes.

Students come to university not just to worship what is known but to challenge it. And if that includes a certain sense of irreverence for their teachers all the better. Certainly, we should expect a certain sense of symmetry between staff and students: if students are to be censured for a certain behaviour, then it is up to staff to produce robust evidence to support why this behaviour is wrong. (Otherwise the staff should get PPD concerns raised too!). For instance, a paper last year in Med Ed tried to incriminate lack of attendance at lectures with an inability to turn up for work— but without any empirical evidence (see also a response). I find this a little sinister. Professionalism has to be subservient to evidence, not vice versa.

I never went to lectures beyond year 2 at medical school (year 5 was lecture free anyway, whereas for years 3 and 4 lectures were four afternoons a week). I had struggled in the first two years, and during my first clinical attachment in year 3, a paediatrician, Nigel Speight, picking up on my sense of failure, suggested to me that I might be better using the library instead. I did, and I owe him a great debt of gratitude. Of course, many students like attending lectures. That is fine too, but compulsion seems misplaced.

Richard and Jamie I think get it right. The argument has to be based on evidence and faith in our assessment methods, and whether we can produce evidence about the efficacy of our lectures. The problem, however, is that I do not think lectures are a natural kind. Most of us have been spellbound by lecturers like AJP Taylor (no notes, talk to the camera), Jacob Bronowski, Richard Feynman or, in more recent times, Michael Sandel (iTunes University if you want to watch). But most of our lectures, nor lecturers, are like that. Think of year four, prior to the SSC and senses module, where around 30 or more lectures are delivered within 5 days. We know from our own research that students do not consolidate the material and for these sort of events, I think Carl Wieman — the Nobel Laureate in physics who has been trying to improve US STEM higher education— has got it right: most lectures perform badly in terms of promoting learning.
Many believe that the key feature in determining learning is intellectual challenge as you focus on the material. This seems intuitively attractive. Remember Herb Simon’s mantra: “Learning results from what the student does and thinks and only from what the student does and thinks. The teacher can advance learning only by influencing what the student does to learn.”
In a paper in Science 2 years back, Carl Wieman showed how you could achieve this, even with less well trained staff, for a large audience. The issue is of course, to what extent this model is transferable to medicine. Asking whether lectures ‘work’ is a bit like asking whether ‘drugs work’. Yes, if you give the right dose for the right indication following an accurate diagnosis etc. To develop this type of lecture, we would, I think, have to drastically reduce the numbers of lectures. Such a transition needs to proceed slowly, and with proper measures of learning (and not just ‘feedback / course evaluation’ please).

But Neil, the debate is more than timely, and thanks for posting. Even without the MOOC hyperbole, any forward looking institution has to ask what value it is providing to students —student debt is, as we are reminded, larger than credit card debt in the US. And once you say that a core component is sitting in conventional lectures, why would students pay for that, when you can increasingly obtain the same online for free. If you lecture to 300, why not 30,000 with a commensurate drop in unit cost. Why does each medical school need to provide the same basic lectures? Why not see which are best, and buy those in? Institutions are likely to oppose unbundling and disintermediation, but then that is what the Web allows.

Value  for the student now will have to come from something else. In clinical medicine we have always been able to dodge this issue by saying it is about bedside teaching. But we all know there are real constraints there too, not least in England as units that have previously taught students have now been outsourced to Circle or ISTCs (so the clinical material has moved, but the students haven’t). Perhaps somebody can correct me, but in England medical school fees are going to cost over 50K over the lifetime for a consultant (the additional 9% tax over 30K etc and knowing that you are paying for the 50% of the graduates who will not pay back their loan). Interesting times.

Similar debate about lectures over at computing education blog but without the compulsion bit, and a recent paper in the NEJM.  Finally, Rich DeMillo gets it right about an awful lot of things

There is a message in the journey that higher education took from Peter Abelard to Apple Computer: professors who do not provide value, who are excessively, inwardly focused on the concerns of their profession, who confuse lecturing with teaching, who confuse scholarship with winning sponsored research grants, are usually swept to the margins.


Post by Jonathan Rees

Clinical academic and skin watcher at the University of Edinburgh

3 Responses to Make lectures in medicine compulsory?

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