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May 25, 2012
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Ilana Yurkiewicz is a third-year student at Harvard Medical School who graduated from Yale University with a B.S. in biology. She was a science reporter for The News & Observer in Raleigh, North Carolina via the AAAS Mass Media Fellowship and then went on to write for Science Progress in Washington, DC. She has an academic interest in bioethics, currently conducting ethics research at Harvard after previously interning at the Presidential Commission for the Study of Bioethical Issues. Follow on Twitter @ilanayurkiewicz.
Ilana Yurkiewicz is a third-year student at Harvard Medical School who graduated from Yale University with a B.S. in biology. She was a science reporter for The News & Observer in Raleigh, North Carolina via the AAAS Mass Media Fellowship and then went on to write for Science Progress in Washington, DC. She has an academic interest in bioethics, currently conducting ethics research at Harvard after previously interning at the Presidential Commission for the Study of Bioethical Issues. Follow on Twitter @ilanayurkiewicz.
A few weeks ago, I wrote about creativity. With its emphasis on requirements and contrived benchmarks of success, medical school admissions might inadvertently be selecting for those who are skilled at jumping through hoops and weeding out more independent thinkers. I received comments from people who were so inspired that they wanted to discuss ideas about reforming the curriculum. Creativity is missing; how are we going to fix this? It was the epitome of irony to me: attempting to standardize the exact thing that refers to thinking outside standardization.
In this post, I hope to address my thinking about the subject in a bit more detail. I believe excessive curriculum mandates are a well-meaning but counterproductive approach to solving what we are aiming to solve.
The temptation to improve education through mandates is not new. Every few years, medical administrators, politicians, or some other Powers That Be decide an important quality that all doctors should have is not being taught, and that it must be standardized into medical education. Focus was first on mastery of the hard sciences, then turned to increased emphasis on compassion and communication. The latest has been a turn to the medical humanities, with endeavors such as visiting art museums and engaging in poetry-writing sessions becoming increasingly widespread. At the end of 2011, 69 of 133 accredited medical schools in the US required a course in the medical humanities.
Medicine is holistic – a blend of science and art – which those inclined to suggest reform rightly realize involves far more than repairing the human body when it malfunctions. The medical humanities, as a field of study, is invaluable. The question is: should it be required?
Fourth-year medical student Rhys Davies has reservations: “Asking students to compare the role of literature in sickness between Broyard and Mantel is pointless unless they want to get something out of it,” he writes. In fact, he says, it’s because he cares so much about the medical humanities (he is completing a thesis in it) that he opposes its obligatory presence in the curriculum. The setup is bad for everyone. Those not interested are miserable, and those who are have a mediocre experience tainted by the heel-dragging of their peers. As Davies puts it, “Anything compulsory is duly attended but interest is notably absent.”
That is not to say there is no worth in a well-rounded curriculum. There is value in exposing students to diverse ideas and activities, perhaps sparking new passions that never would have been discovered otherwise. There is something to be said for making students do things considered good for them. Mandate nothing, and people might not learn enough. Some need that extra push. They might gripe along the way, but then say after, “I’m really glad I did that.”
But place too much emphasis on curriculum, and the downside is exacerbating a culture of excessive busywork at the expense of some of the most meaningful ways of learning. The knee-jerk desire to reform curriculum whenever a desirable skillset is identified is based on a particular assumption: that every skill is best learned through the medium of coursework. Unfortunately, that assumption just isn’t true.
There is a wonderful ethics professor here at Harvard, Dr. Edward Hundert, who has written a lot about the “informal curriculum” of medical school. A significant transmission of culture happens outside classes, hospital rounds, and the like, he says, over meals or during carpool rides from remote clinical sites. From focus groups with students, he found that “the vast majority of the situations the students described as most influential were conversations with no faculty present.” He concluded: “I have discovered just how little a role the formal ethics curriculum plays in the moral and professional development of our students and residents.” We succumb to the mistake of emphasizing teaching, when what we really ought to focus on is learning.
That can occur in many ways. Dr. Faith T. Fitzgerald, former dean of students at the University of California, Davis, School of Medicine, understands this well. She boldly challenged a request from politicians that more humanities coursework be added to the medical curriculum, explaining: “[I was concerned that] the addition of required courses in literature, drama, sociology, music, and art might actually limit students’ opportunities to read, go to the theater, be with friends and family, and attend a symphony or museum.” Even if they would not have done these things, she continued, the additional coursework would “cut down on contemplative time, volunteerism in free clinics, hobbies, and sleep.”
Requirements come with an inherent trade-off. With the medical part of medical school demanding enough, free time is a commodity. Soak up our time with mandates aimed to make us well-rounded people, and we have less time to actually do the things, outside the narrow confines of a formalized curriculum, that make us well-rounded people.
Nearly any quality under the sun can be justified as valuable for a doctor to have. What would happen if we continued along the path of standardizing them all? One possibility is imitating what is already happening to poor pre-medical students, who, along with having to fulfill course requirements rigorous enough to constitute a major of their own, will in 2015 have to endure a new MCAT: six hours long, thanks to the addition of psychology, sociology, and ethics on top of existent sections in physics, chemistry, biology, verbal reasoning, and writing. Escalate this any further, and doctors-in-training with creative impulses will have zero time to pursue them.
To cultivate knowledge of the humanities or any other valuable trait that makes it to public discussion, I believe that the “informal curriculum” idea hits the nail on the head: change the culture, not the requirements. What reformers need to realize is that medical students are independent, mature adults, with interests and passions we know how to follow – if placed in the right environment and given the time. Some are spouses and parents; some love volunteering, reading, writing, research, music, sports, art, exploring the outdoors, good conversation. I promise, we know how to do those things. And we get more from the pursuit of activities we care about than from narrow mandates that attempt to force desirable traits upon us by decree.
Poetry as reflection, visits to art museums, and other programs in medical humanities are beneficial resources, and they should exist. But participation should be elective. For each activity, there will be students who want to join, and those who show up will genuinely care about what they are partaking in. Those who opt out have different passions that they know how to follow, too. Medical schools should trust their students to do so.
About the Author: Ilana Yurkiewicz is a third-year student at Harvard Medical School who graduated from Yale University with a B.S. in biology. She was a science reporter for The News & Observer in Raleigh, North Carolina via the AAAS Mass Media Fellowship and then went on to write for Science Progress in Washington, DC. She has an academic interest in bioethics, currently conducting ethics research at Harvard after previously interning at the Presidential Commission for the Study of Bioethical Issues. Follow on Twitter @ilanayurkiewicz.
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One thing I like about my local medical school is the option to do some self-directed project or do some community service projects. Not every second year student chooses these options but those who participate can do some amazing things! I’ve been a mentor to students working in prisons, working in palliative care, and students doing research on the effectiveness of some of the curriculum ideas – and more.
Link to thisYou are right that it should be optional and somewhat open. Trying to standardize it can take away some of the benefits.
Experiential learning in self care and health promoting practices would benefit both the student trying to survive medical school and their future patients. Humanities with a experiential focus could tie in through offerings in expressive (healing)arts such as music, art, dance, play, drama, journaling and creative writing, meditative and movement practices such as yoga and qigong. And perhaps giving weight to medical school applicants who have pursued these areas would encourage perspective students to start or continue taking classes during their undergraduate studies.
Link to thisMedicine is a profession like a motor mechanic
When repairing a gearbox there is a proceedure to follow, not much space for creativity, we don’t add or remove a cog and hope it will still work
Providing medical service is a science not an art
When performing heart surgery or prescribing medication, we also don’t have much space for creativity
As with the mechanic if we wish to be creative we specialise, post doctural research in a field that holds our greater interest.
Many University degree courses are focused on one dicipline with no arts or humanities breadth subjects, no need to single out medicine
Why single out universities for stifling creativity, we start that at preschool and continue right through the educational system
Link to thisMedical schools face a daunting challenge, since loans make up a large amount of tuition payment, the schools must take students who have shown the ability to memorize and give right answers to testing. A recent study has shown a correlation between MCAT science scores and success in school arguing that point. This means future docs are well versed in learning A and treating with B without much leeway for creativity. Best standards and practices (based on studies done by many drug manufacturers) make it even harder to try alternative treatments without incurring the wrath of state medical boards. Since most of these standards rely on double blind studies, the chance that acupuncture, hypnosis, Osteopathic and Chiropractic manipulation will ever be recommended as primary treatment is slim. I was told by a physician that may doc’s are leaving the profession due to their very lack of ability to be creative. Obama care will make this situation far worse. Many studies done by drug makers have “shown” the treatments I used in my office don’t work in spite of the success my pt’s found with them. 8 years ago or so pt’s spent over $25B on alternative health care, I don’t think you pay for traditional and alternative care because the traditional care is working that great. Doctors have to practice to protect themselves from malpractice and state medical boards, visits get shorter, more testing is done to make up for shorter visits and the cost of care goes sky high. The problems in medical care will only get worse before getting better until the idiots (law makers who have no idea the challenges of medicine) actually listen to the people (pt’s and doc’s) who have to deal with these problems day to day.
Link to thisI agree with you that it would be counterproductive to mandate additional specific humanities courses.
I also wanted to add that there could also be some use in finding ways to reduce the overall stress levels of medical students. For instance if they expanded residency funding to open up more future so students don’t have to be so competitive and stressed about the uncertainty of getting into the field they want.
Link to thisWonderful! An interesting post…but the reality is that the “hidden curriculum” of medical socialization and mandates of the medical school curriculum feeding the USMLE/COMLEX beast crushes many more souls than a couple of essays in a lone medical humanities class. Busywork, whether for biochem or for reflective writing, has no place in medical education. There is simply too many important things to learn. The desire to tinker with the medical curriculum with every new “requirement” (whether it is from the Lancet Commission, UN MDG’s or USMLE) is really what Ilana Yurkiewicz is railing about (I think!). Good for her in pointing it out!
Link to thiso corpo humano nao e maquina.
Link to thisEnfermidades sempre evoluem e transformam.
Criatividade e bom para medicina.
Great article. The American education system is notorious for emphasis on breadth of knowledge instead of depth. But sometimes less is more. And as the author suggests, people need time and space to independently pursue their interests. Independent learning nourishes motivation.
Link to this“Requirements come with an inherent trade-off. With the medical part of medical school demanding enough, free time is a commodity. Soak up our time with mandates aimed to make us well-rounded people, and we have less time to actually do the things, outside the narrow confines of a formalized curriculum, that make us well-rounded people.”
Agreed. But is this really specific to medicine? It seems to me that the entire academic and economic treadmill, from age 3 to retirement, is designed to minimize the amount of creative time one is exposed to – to layer excessive structure upon a process that needs flexibility to thrive. Creativity is facilitated, not forced, and if we attempt to do the latter, we risk simply adding yet more structure in the form of a “creativity requirement” into the system. What we should be doing is creating an environment which organically promotes creativity, then giving students enough free time within it to come up with and pursue some of their own ideas.
Link to thisHi Ilana. Great post, and great insight. Several years ago I was placed on leave from medical school in my senior year to be with a terminally-ill family member, and I later elected not to return.
I think your analysis is spot on- further “mandates” would likely breed greater resentment among medical students. But I sincerely believe medical schools (or at least the medical school I attended) need to change their culture. There seems to be a real lack of creativity and vision within the medical profession today. Consequently, I think this is going to have a real detrimental effect- I expound on this more in a recent article “Why Your Next Doctor May be a Computer” http://ow.ly/bduk3
Link to thisDecades ago, somebody said that it can take around 4 years to recover from the mental castration the pass thru an university produces. Is this true today?. Salut +
Link to this