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.