180 BioEssuys Vol. 1, No. 4

Laboratories and Examinations in Medical Education

-

Karl H. Muench

Medical education is predicated on science, and learning to assess data critically should be at the core of a medical curriculum. Participation in re- search disciplines and matures the mind of a medical student. These statements, although self-evident to medical edu- cators, may perplex medical students, whose experience of science has be- come an uncritical recitation of facts, memorized for examinations. Here, I contend that decreased laboratory experience and exposure to multiple- choice examinations in the preclinical sciences work in concert to hinder true education and distort perception of science.

The de-emphasis of research and of laboratory exercises in the medical curriculum has strengthened the relative impact of the lecture hall in the teaching of preclinical science. Contrary to majority opinion, the content and nature of lectures in turn is determined by the content and nature of examina- tions, not the converse.

With the exception of the anatomical sciences, laboratory sessions have vir- tually dropped from the preclinical curriculum. Fewer medical students now profess the desire to enter research careers. According to a study by the U .S. National Academy of Sciences,’ the number ofmedical studentsassigning high priority to research dropped from 9% in 1963 to 2% in 1976. I see no evidence for a reversal of that trend.

Harold Schoolman has eloquently stated2 that the only role for which a physician is indispensable is that of the patient advocate. In this role the physician makes decisions in the face of the uncertainty that arises from incom- plete and imperfect data. Major prepara- tion for this role is exposure, or better immersion, in the discipline of science, which teaches the critical assessment of data in place of the passive acceptance of dogma. In clinical practice the flow of events often demands decisions, whether or not the physician is fully informed and prepared. As Claude Bernard said, ‘Medicine is a science forced to practice before it is ready.’

What changes in the student should a medical education catalyse? The great American jurist Harold R. Medina wrote this about his college education:

‘The greatest thing I learned was how to think. One day it dawned on me that I was no longer repeating what the professor told me, but for the first time I was thinking for myself. . . Developing a disciplined mind is a gradual process, but once you have it, it is there for life. Whatever comes up. . . you can handle it.’3

Does our medical curriculum catalyze such transitions in medical students? Let us examine our preclinical science instruction. Our major vehicle remains the lecture, which flourished in the Middle Ages because of the shortage of books. Someone once said, ‘A lecture is the process by which the notes of the professor become the notes of the student, without passing through the minds of either.’ Too often our scheduled sessions lack stimulating dialogue, con- sisting instead of dry recitations of fact. According to a report of the American Association of Medical Colleges (AAMC),4 ‘The basic sciences, taught primarily in lecture format, foster passive learning of fragmented facts and provide little room for knowledge attained by self-discovery and reason- ing.’ The report goes on to state, ‘There is unanimity in deploring that students are submerged by details and memoriza- tion of facts, that the amount of information taught during the preclinical phase is excessive. . . .’ Another observer has ~ommented,~ ‘There is no evidence that keeping medical students in a passive mode for the first two years of medical school is accomplishing the basic objectives of education. Students are stuffed with the facts of basic science, but the behavior of a scientist escapes them. . . .’

The current state of American medical education has evoked expressions of alarm.6 I here suggest that submersion of students in overwhelming detail is a symptom rather than a cause for the malaise in medical education. Other symptoms, as verified by other observers,6 are demoralized teachers, adversarial to non-existent student- faculty interactions, and disillusioned students. The latter are perceived to be anti-intellectual in outlook as their growing cynicism leads to decreased participation (poor lecture attendance) and sometimes even to chronic depres-

sion. These conditions exist even though the proven ability and potential of both faculty and students, coupled with the exciting nature of current biomedical advances, would instead predict joy and enthusiasm in learning.

I submit that the underlying cause of these symptoms of illness in medical education is the failure of faculty to properly execute the evaluation of students,’ because ultimately the mode of evaluation determines the content and performance of teaching. Perhaps Sir William Osler went too far in saying,8 ‘Perfect happiness with student and teacher will come with the abolition of examinations, which are stumbling blocks and rocks of offense in the pathway of the true student.’ But what do our examinations measure? What do they evaluate? American medical facul- ties have surrendered the evaluation process to the tyranny of computer- graded, multiple-choice examinations, modeled after those of the National Board of Medical Examiners (NBME). Of this multiple-choice mentality the AAMC report4 states, ‘It is the general view that while some conceptual capa- bility is measured by the NBME examination, it primarily measures re- tained information.’ Multiple-choice examinations engender, by their intrinsic nature, fact-memory questions, which in turn breed fact-stuffing lectures. After all, it is only fair in a lecture to emphasize the facts whose recall is required for the examination. The highest grades go to those who recall the most minutiae. Succinctly put,e ‘Despite faculty statements about broader educa- tional objectives, students will memorize facts as their principal educational skill to pass those tests. Faculty will teach to those tests by providing extensive in- formation to be memorized.’

Fact-stuffing lectures stifle critical thinking and love of learning. What of the problem-solving skills, vital to the physician in his role as patient advocate? The answer is clear:4 ‘ . . . teaching facts, memorizing facts, examining facts, and contriving problems in reasoning for an examination give no indication of what physicians’ problem-solving behavior will prove to be in real life under real pressures. We must recognize the error in the belief that problem-solving ability

BioEssays Vol. 1, No. 4 181

ED U CAT10 N can be taught and tested by means of present educational premises and tools.’

Of course, the roots of the fact-recall problem go deeper than medical school. Despite lack of demonstrated corre- lation of Medical-College-Admission- Test (MCAT) scores with superior performance in medical careers, 124 of 127 American medical schools require the multiple-choice MCAT for admis- sion, whereas only 13 require the baccalaureate degree.1° In the words of a physician who took the examination while serving on his medical school admissions committee,” ‘ My feeling about the entire [science-knowledge and science-problems] portion of the test was that it measured recall of facts rather than cognitive function or reason- ing ability. It was dry, dull, and by-and-large totally unrelated to the practice of medicine. Unfortunately, it brought to mind the usual approach to the basic sciences in medical school: memorize for the exam, then forget; for it seems you rarely use the facts again.’

One tragicomic result of the fact- stuffing in medical education is the behavior of many students as they enter the clinical phase. Dependent on note- taking, they write a medical history while the patient speaks, as if at a lecture. Subsequently they present the history to the attending physician by reading from the notes! After the preclinical curriculum our students are

conditioned to believe that success and security hinge on factual memory. Subsequently and consequently, in face of difficult questions from patients, these physicians fear the simple, honest reply: ‘I don’t know.’

Perhaps more damaging is the subtle effect of fact-stuffing on the perception of, science by medical students and physicians. In the absence of first-hand research experience, medical students may misunderstand or misperceive science as the intolerable memorization process to which they have been subjected. The misunderstanding may extend further: at least one preclinical educator has misinterpreted the AAMC criticism of fact-stuffing, accusing that organization of attempting to ‘ . . .down- grade the role of science in American medical education ’.l2

Direct research experience is an avenue for medical students to accom- plish the metamorphosis described by Harold Medina. Possession of a disci- plined mind would then allow a graduate physician to fulfil the role of patient advocate. Experts believe that the barriers to reform in medical curricula are formidable. Therefore, to expect early reinstatement of significant labora- tory experience is probably unrealistic. But to decrease reliance on multiple- choice examinations as the major method of preclinical evaluation would be a corrective that is practicable now.

REFERENCES 1 BROAD, W. J. (1979). No cure in sight for loss of M.D. researchers. Science 205,2628. 2 SCHOOLMAN, H. M. (1977). The role of the physician as a patient advocate. N.E.J. Med.

3 MEDINA, H. R. Quotedin ‘ Judge Medina’s Legacy’ by Virginia Kays Creesy. Princeton Alumni Weekly, April, 1982. 4 AMERICAN ASSOCIATION OF MEDICAL COL- LEGES. (1983). Emerging perspectives on the general professional education of the physician. 5 WEED, L. W. (1981). Physicians of the future. N.E.J. Med. 304, 903-907. 6 ROGERS, D. E. (1982). Some musings on medical education: is it going astray? The Pharos, spring, pp. 11-14. 7 JASON, H. & WESTBERG, J. (1 979). Toward a rational grading policy N.E.J. Med. 301,

8 OSLER, Sir W. (1907). After twenty-five years. Aequanimitas, with Other Addresses. 9 BARROWS, H. S. (1983). Problem-based, self-directed learning. JAMA 250,

10 ANDERSON, N. D. (1984). The MCAT malady. N.E.J. Med. 310, 396398. 11 POWERS, R. D. (1984). The MCAT revisited. N.E.J. Med. 310, 398-401. 12 SCHWARTZ, H. (1982). Revolt against flexner. Private Practice 14, 31-36.

2%, 103-105.

607-6 10.

3077-3080.

K A R L H. MUENCH is at the Diuision of Medicine, School of Medicine, University of Miami, Miami, Florida, 33101, U.S.A.

I

EDUCATION/SCIENCE AND SOCIETY

Features on ‘Education’ and ‘Science and Society’ will be a regular part of BioEssuys. The former will deal with the implications of the new biology for education, principally at the tertiary and post-graduate levels, and the effectiveness of current educational practices. The ‘ Science and Society’ features will discuss the current ethical, social and legal issues raised by the new biology. Similar issues will sometimes be treated from an historical perspective in articles such as those in the series by DeWitt Stetten and his colleagues.

Contributions from readers for either of these feature columns will be considered. Readers wishing to suggest timely topics and authors (themselves included) for ‘Education’ should contact Dr Karl Muench, University of Miami School of Medicine, P.O. Box 016129, Miami, Florida 33101, USA. For ‘Science and Society’, prospective contributors should write to Dr Alexander M. Capron, Georgetown University Law Center, 600 New Jersey Avenue, N.W., Washington, D.C. 20001, USA. If the topic concerns regulatory matters, then it should be addressed to Dr Henry I. Miller, Food and Drug Administration, 14B 19 Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857, USA. Those who would find it more convenient to communicate with the Staff Editor, Dr Adam S. Wilkins, may do so at the Cambridge University Press, The Edinburgh Building, Shaftesbury Road, Cambridge CB2 2RU, UK.