Sunday, January 07, 2007

What’s in a curriculum?

My beautiful chia kitten - a white elephant gift from my small group leader.

(This entry is particularly for all the pre-meds reading this. A note to all of my family members: I'll try to keep it interesting for you, but bear with me on this one.)

I've been thinking a lot about our curriculum, and how we, as medical students, learn. As a student who has sat in an incredible number of lectures (I haven't counted them, but it must be in the thousands by now) over the last year and a half, as well as component representative for my class (read: the liason between the faculty for each sequence and the students), I have learned a lot about what works and what doesn't. Lists of facts do not work well - and reading them aloud doesn't help. Reading the same facts over and over is better, but is still boring. Lecturing about the concepts that support the facts is yet again a step above. Discussing those facts and concepts as they relate to cases is even better, but it takes a lot of time and a large number of well-trained dedicated faculty members. Discussing those facts and concepts while looking at relevant pictures/objects (sound like a lab?) is probably the pinnacle of this hierarchy I'm describing here. (As an aside, none of this should seem novel to anyone who has sat through two consecutive lectures or discussions, one good and one bad. I just wanted to bring everyone up to speed.)

So why does our curriculum (and that of many medical schools) so often stop at the lecture stage of things, instead of going on to small group discussions and labs? I have asked myself this question many times and have come up with lots of different answers. Firstly, I suspect, is the issue of time. We pack an incredible number of structured hours into our class time, and lecture often seems to be the most concentrated way to transmit information from teacher to student. While at the end of a 6 lecture hour day we may all be reeling, we have all the notes we need to study an incredible amount of material. Secondly, I'm not sure we have enough faculty free to teach the number of hours they would need to in order to create small groups for each topic. Additionally, as pathology lab and small groups so frequently demonstrate, a good discussion is most often the result of thoughtful processing of material that we have already learned. While we learn a lot while we discuss, it's generally not about facts and mechanisms but rather different approaches to problems.

This seems to strike at the heart of the debate between "problem-based learning" and lecture. While I am by no means an expert on medical education I think my experiences put me in a unique place to comment. While admissions folks throw around all kinds of language about curricula, and most of it seems to make sense while they are saying it, one should always consider the source. I'm not saying you shouldn't believe the admissions officials, just saying that what they tell you is probably slanted toward getting you to love the particular school you're visiting. So here are my thoughts: everyone needs a balance between what are often described as two different approaches. In my experience problem-based learning on its own leads to interesting discussions, but frequently leaves gaps where the conversation didn't go or no one had anticipated needing additional information. On the other hand, lectures alone can leave the material dry and boring, as well as leaving many of the finer points without discussion (leaving medical students with the unfortunate impression that science is exact... oops!). A combination of the two allows students to get a broad understanding of the subject at hand and ask questions about the beautiful complexities.

There is clearly a flaw in my discussion, however, and it is as follows: I have been educated in the US public school system for the last eighteen and a half years. I have only rarely experienced methods other than those described above. Many of my courses in undergrad were based only on discussion - and relied on students to read before class to supply the background information. This worked variably well depending on the amount of material that was necessary to make discussion interesting and the willingness of the class to speak. Others were based solely on lecture - and relied on students to discuss outside of class to supply the variety of approaches to the problem. Yet I know there are other methods out there: many of my classmates have unique systems of streaming video, reading, and study groups, all finely honed to be as efficient as possible. I've tried different things, and found what works well enough for me, though I often wonder if there weren’t something better. So here is my challenge to you: consider that you, rather than your medical school or your educators, are responsible for learning all of the material presented during medical school. They are certainly critical conduits for information, and important sources of explanations and clarification, but the main burden lies with you. Consider what you need to take this responsibility and look for the medical school that offers the right tools to help you along.

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