A sequencing problem

I think sequencing — the order — of how we put teaching together is a big issue in medical education. Not the only big issue, just one of a handful. Historically medical education hid behind the idea of education as a form of apprenticeship. There is a lot to be said for post-graduate medical education as an apprenticeship (despite the attempts by the NHS and HR (aka postgraduate deans) to kill it off). But at the undergraduate level it fails; class sizes are too large; the sense of belonging gone; specialisation has led to lots of small attachments; and nobody has been quite certain how to deliver teaching when the responsible body is a university, but where the patients are physically located in the NHS.

In some mythical far distant past, students would be lectured to, and then appear on a ward where they would be supervised, mentored, and where their progress would be monitored in real time (as in real feedback). And many of those delivering the teaching, would know exactly what standards would be expected of the students. This is not how it works now. No surprises here then. Like much of modern education: it doesn’t work.

Even when I was a student the clinical attachments through year 3 and 4 would be in the mornings, with lectures in the afternoon. The problem was that the two activities were out of sync: the mornings might be spend in paediatrics, but the lectures could have been on geriatrics. The time hallowed linkage between seeing patients and reading about them was rendered problematic. My solution was to not attend lectures. It worked for me 🙂

There were attempts to get round this problem. Dermatology teaching in Newcastle in those days was made up of 4 weeks of clinical mornings, but the lectures were delivered on another ‘out-of-phase’ period, and each afternoon, after say a lecture on psoriasis, 10–15 patients with psoriasis would appear, along with 10–15 staff who would demonstrate physical signs and patient stories, to students. You needed a lot of staff, and a lot of seminar rooms, and seminar rooms close to each other (i.e. a medical school). When I was in charge, I kept that system going for a few years, but eventually we had to abandon it due to a lack of resource and central support (‘who is paying the patients’ travel expenses’).

The prompt for for all of this is merely to remark how badly we organise or instruct what we want students to know before they appear on the ‘wards’. Tech allows us to think of ways to do this that were simply impossible 20 or even 10 years ago. But it needs a sea-change in how we view medical education. And much as I fear the expropriation of medical education from the ‘ward’, (simply because bedside teaching is so expensive) we have to think hard about allowing our students to take most advantage of the clinical exposure we can provide.

So, we started a new academic year this morning. The first group of students — there will be another 17 groups this academic year — who will spend two weeks with us throughout the year. And what surprised me, and cheers me up enormously, is how, when medical students are given firm and coherent guides as to what to cover by themselves, they can, with little interaction, achieve so much (connectivists and social constructivists, please note). And when you then interrogate them interactively on these topics, you can feel and see them struggling (successfully) to make sense of so much new material. And with an evident sense of pleasure and achievement.