George L. Anesi is a third-year medical student at Case Western Reserve University School of Medicine pursuing a dual degree program as a graduate student in the Department of Bioethics.
Medical education in the United States is in the process of a major paradigm shift away from traditional, subject-based, lecture-driven curricula in favor of integrated organ system-based curricula, characterized by a structured, small group format. The medical school at which I train, Case Western Reserve University, will this year graduate its first class from the Western Reserve2 curriculum (.doc) fashioned in just this method; countless other schools are soon to follow.
The etiology of such a shift is complex, and includes multiple factors including a desire for a more clinically-correlated first two years of medical school, an expansion of contemporary medical knowledge beyond what can logistically be taught via lecture, and a realization that sitting in lecture halls for hours on end may not be the most effective method of knowledge transfer.
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As more and more schools take head of this paradigm shift and modify their curricula accordingly, the role of the lecturer in medical education has come under new scrutiny. With fewer lecture hours in newly reformed curricula, the need to make those hours worthwhile has become an imperative. It has forced the general question of what makes a good medical school teacher, but also the far more important question of what makes a good teacher within this new format of medical education?
We all, to a certain extent, know what makes a really good lecturer, even if we cannot articulate it. They are individuals who are naturally engaging to a point such that they could give a talk on the maintenance manual for your dishwasher and people would bring their lunch to attend. I suspect these unnamed qualities cannot be easily taught, especially to attending physicians and researchers with established personas. More effective than attempting such a feat would be to define how to use lectures in new curricula.
With a limited amount of lecture time, it is neither effective nor possible to have a lecturer describe the pathogenesis, clinical features, natural history, and treatment modalities for every clinical entity in Harrison’s Internal Medicine. Two distinct approaches, however, are effective for lecturers in this new type of medical curriculum: (1) lectures on particularly difficult-to-understand topics that are so common and/or fundamental that comprehension of them is essential to medical practice, and (2) lectures that provide conceptual approaches to clinical investigation and treatment that are applicable to a wide range of pathologies.
Part one is relatively simply. Medical students need lectures on diabetes and heart failure, for instance; these are difficult to understand topics and their understanding is essential to good medical practice. While the list of lecture topics that would qualify for this category is absolutely large, it is a small percentage relative to the list of all possible lecture topics.
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Part two—the conceptual lectures—is more difficult. There is simply no time for a lecturer to cover all the causes of anemia; the bullet list of etiologies for a low red blood cell volume or hemoglobin concentration is staggering. However, one of the single best lectures I ever attended during medical school was from a hematologist on evaluating the anemic patient. The bullet list of etiologies was replaced by a paradigm for considering anemia: low red blood cell counts can be due to (1) decreased production, (2) increased destruction, or (3) loss (e.g., bleeding), and nothing else. From that framework, we were shown that other elements of the medical history and laboratory data are used to further branch the anemia tree. In the end, the details of each cause of a low red blood cell count can and should be hashed out by individual students in whatever method they feel most comfortable; it is the approach to evaluating a patient who presents with such a blood count, however, that is best taught by an expert.
With fewer lecture hours, we need to cast a wider net. By way of another example, a lecture on the natural histories and treatment sensitivities of individual cancers for a given organ may not provide something that a book could not; a talk on the genetic and cellular theory of oncogenesis—applicable to all cancer development—will, however, produce more sophisticated physicians and researchers. These are the types of lectures we need; the best teachers are those who will be able to deliver them.
So, who are these teachers? Beyond the prerequisite of that intangible ability to inspire interest from their audience whatever the topic, these teachers are those who can identify those conceptual points in a given biomedical topic that are fundamental to understanding the larger picture.
Returning to a previous example, a medical student without the benefit of the lecture I attended when asked to cite causes of anemia might begin to name various etiologies as they came to him or her. By pointing out those three fundamental categories of anemia—decreased production, increased destruction, and bleeding—anyone who was in that lecture with me will now have an effective framework from which to start. Furthermore, while clearly useful as a tool for clinical evaluation, this framework, as an example, is also useful in our independent studying when we actually learn all of the different causes of anemia one by one. Trying to memorize that huge bullet list without such a framework is relatively futile; instead, I can appropriately file away iron deficiency into “decreased production” and sickle cell anemia into “increased destruction” and in that way truly learn the material.
The underlying point is that the best lecturers are those that can see what conceptual points will be the most useful tools for medical students pounding away at the books; what descriptions will give students those “ah ha” moments when we actually understand anemia or cancer or any other clinical entity. Such a skill is harder than it looks; indeed, one of the more challenging feats is for physicians and researchers who have understood anemia or cancer or heart failure for decades to figure out what was it that made them understand in the first place.
