Choice comes with costs

Awhile back I was chatting to a student. We had met say half a dozen times over a few years, and we gossiped widely. He was now returning back overseas, setting out on a surgical career after deciding that the UK postgraduate system wasn’t as good as he could get elsewhere. As we parted, he thanked me for the various conversations, muttering that it was good to hear how things had been in the past. I might have taken it as putdown — like when my children were younger and any conversation about ‘olden days’, meaning anything from the past thousand years was viewed as something I had firsthand experience of. The more interesting points are: not all change is good (here is an amateur geneticist speaking), and knowledge of how things once worked is not irrelevant to any future; and second, that often in medicine our thoughts about undergraduate medicine are deeply influenced by our own experience. The problem for me is that this experience was close to 35-40 years ago.

Listening to students is hard. I don’t mean passive listening, but when you try and interrogate students about how they see things, trying to momentarily forget how you see things. And of course, why they see things in a particular way. Listening this way is an act of imagination, which is why it is tough, but worth doing.
One conversation I filed away was about one facet of lectures (and I am not going to digress into the ‘what is the value of lectures’ as I think it is a misinformed trope). A group of students were saying how tedious they found many of them, but when I said ‘why go’ (because I ‘never’ did) they pointed out the main purpose of lectures was to provide information on what might come up in the exam. They pointed out some potent examples of where trivial information was presented in a lecture, and that same factoid came up in an exam (and some of the stories they recall are disturbing: what chromosome is this gene on, for example). So, this got me thinking about how students work out what it is they are expected to know. And my conclusions are that it is at least worth considering that things are worse than they were once for me.

First, we need to set aside learning outcomes. Conceptually they make lots of sense, but as implemented operationally in medicine they are often dreadful (I have written before on this topic, so will not repeat myself). They are a giant pretense of apparent order.

Why do I think things may be harder than they were for me? Well, if you decrease the frequency of lectures, and lectures — however bad and inefficient for this purpose — serve as the index of what has to be learned, you are left with a problem. Then think about books. I do not have empirical data, but it seems to me there are more and more books on any  in undergraduate medicine, and if you compare different books the differences for a learner are not trivial. In any case, many books for dermatology that are said to be for students are aimed at multiple markets. It makes no sense to ‘learn the book’.

Then there is the web. So much there, so much good stuff, but lots of inaccuracy, and again not matching of content to learner’s stage. How do you treat recommendation about what is good, and the ‘search cost’ in finding that which is good, and the power of modern social media and communications to magnify and echo both what is good, and what is bad? You have to think about recommendation errors, errors in fact, and matching of content to your course. The latter point, matching to a course, is something we do not talk much about. You only have to visit two medical schools 50 miles apart and look at how curriculum time is allocated, to seriously question whether student’s can reasonably learn the same things. (Or perhaps consider the possibility that the real metacurriculum is the one the medical school publishes). Finally, the web is wonderfully anarchic, but format and approach to several different domains might benefit from some similarities in pedagogical approach — perhaps. And meaningful curation is not much in evidence.

And what about the teachers? Well, this is an easy one. There are more staff, more students, more compartments (as in specialties), and staff time is ever more fragmented. There may have never been much coherence to a medical school syllabus beyond thinking it was what you had yourself received 20-40 years earlier, but for many who teach medical students, the ‘course’ is an alien place situated somewhere between the GMC, the medical school, the NHS, and what interests — or bugs —the teacher. Education and scale are not easy bedfellows, even if all the people doing the teaching were professional educators.

In many things to do with teaching, to borrow some words from Larry Lessig (and Cass Sunstein), I am a libertarian paternalist. My take on this is that the oft quoted complaint about students — ‘they want us to tell them the exam questions!’— may reflect a genuine sense that students really know less about what they are supposed to know that I did all those years ago when the choices were not so legion.