Bug me, as in ‘bugging me’. Things that go round and round in my head, and where I do not know whether what I think is correct, but nonetheless I feel compelled to at worst ruminate, or at best to think I might be right. Standard warnings apply: I often do not agree with myself. And what follows is in no particular order, and worse still, I
might will list some more another time.
- The purpose of medical education is not to train people to be FY1 doctors (interns). Good students will be able to function as FY1 doctors, but many countries to not bother with this step. People learn loads as interns, but that is not a good enough justification for them having to be interns (in the UK sense). All too often junior doctor training is about cheap labour, not education or training. The more you look at international comparisons and practice, the less convinced I am about the UK approach. Time is short, and there are lots of paths to the summit.
- I do not think assessing medical student competence is especially tricky — certainly not in comparison with many other degrees where there are large numbers of students. The core skill of doctoring it taking a story, making sense of it, and being able to tell the patient what is going on, and being able to plan what to do next. I do not think assessment of such skills is problematic, even though it might appear (at first) expensive. We say it is hard because we don’t get up each morning enthused about it.
- We should concentrate on measures of the abilities described in (2) to decide whether to pass or fail medical students. Measures of process do not work well in education (general point, I learned from the writings of Dylan Wiliam). Most of the measures the GMC talk about or insist upon have little evidential basis. You can always game process (which is not the same as saying process isn’t important). The problem is that process degenerates into audit and rituals of verification (Michael Power). The latter is why most NHS postgraduate education (sic) is more human resources than education. The NHS has never educated doctors, doctors have. The trainees know it, too. Audit and measures of process are like parasites in biology: if you are not careful >90% of the biomass is parasitic.
- What I have talked about under (2) and (3) is not all we should think about in terms of educating medical students.
- Certification or signs-offs always come with errors. The more certification you have, the more straightjacketed you are. However, in medicine we have to be stuck with them — to some degree. But much as the class of degree in many subjects would not predict too well how you survive and function in the non-academic world (independent of what ability you brought to university), so we should not expect too much of claims of competence based on undergraduate studies only. If you want to employ somebody,the responsibility is yours, and you are deluded if you think modules on ‘ethics’or’resilience’ at medical school will have lifelong effects on doctors once they graduate. Those nice people at Enron scored well on their ethics models at business school.
- The main threat to the honesty of doctors comes from the organisations and the incentives these organisation impose, rather than their personal failings.
- As people climb up the ladder they know less and less about other branches of medicine. This is a big problem. All to often, opinions on medical education are based on what people experienced 30 years earlier. Big mistake. The same goes for junior doctor training.
- A la Derek Bok, talking about how he only had the time to read extensively about education once he stepped down as president of Harvard, most people responsible for education in medicine, know little about it. Usually they are too busy to learn anything, or they believe there is nothing really to learn. We don’t train to people to teach, nor are their real career paths for such people. We are stuck between educationalists as the ‘bottom feeders of academia’ (as in the incomparable Clark Glymour’s phrase: ‘Almost all advanced degrees held by teachers are in education, which means that they are academically rock bottom.’) and a lot of not so recent work, informing us how people learn.
- Medical schools are much more conservative than they were in the 1960/1970s. They are more and more scared to step out of line, and appear to control less and less of their finances. Does anybody really want to be better than Stanford? [as an aside, the costs are not that wildly different if my figures are correct]. I cannot go back and read George Pickering’s ‘Quest for Excellence’ without a feeling of sadness that we no longer have faith in our ability to create better ways of doing things.
- Thinking is so more enticing when you should be doing something else.