“What makes a half-truth a great half-truth, instead of a run-of-the-mill half-truth, is that a great half-truth, when believed, can actually cause a great deal of harm.”
Dr. Robert Ferrer
Plenary lecture at the Society of Teachers of Family Medicine Annual Conference, May 2014
Worried about healthcare education policy? The physician workforce? Accreditation? Other belief systems that determine who does what, who gets how much, and why? Here are four half-truths about medical education that aren’t helping.
1. Medical schools with students who have higher MCAT scores are better schools
One metric by which deans are judged by their presidents, governing boards, and each other is the quality of their incoming class. The dean then asks the Admissions Committee to get the “best students,” which, left undefined, is easily translated as students with higher MCAT scores, since admissions guidelines rely heavily on applicants’ MCAT scores to determine who even gets an interview. Knowing this, some students try to increase their MCAT scores by attending more expensive colleges and taking pricey prep courses.
This is harmful because . . . A minority of aspiring medical students have access to expensive prep courses or entry to top undergraduate programs. Using MCAT as a barrier to medical school can potentially have an adverse impact not only on the individuals selected for a given class, but on class diversity. We know that many students with MCAT scores 10 points below the national mean can succeed in medical school. The measure of a great school shouldn’t be the average MCAT coming in, but the graduate going out. Let’s take into account a school’s ability to take talented students who are less academically prepared and help them become physicians.
2. An academic milieu makes a positive contribution to a medical student’s education
One hundred years ago, Flexner made a remarkable contribution to medical education when he reconnected medicine to science. This was brilliant and important, and helped lead in the twentieth century to medical schools becoming centers of research. But while research is critical to our society’s advancement, it does not generally make a positive contribution to a medical student’s education. The basic sciences of anatomy, physiology, biochemistry, pharmacology, cell/tissue biology, and pathology are crucial to a medical student’s preparation. Yet basic science departments are expected to hire faculty members for their ability to obtain grants and publish papers. Most of these scientists spend relatively little time teaching medical students and medical students spend relatively little time, if any, in research laboratories.
This is harmful because . . . Basic science departments with major research enterprises are expensive, costing about 30 cents on the dollar. When medical schools estimate the cost of medical education, some of that cost is predicated on the model that research-heavy basic science departments are a critical component to the medical student education part of the medical school mission. This inflates the cost of medical education, which is paid by taxpayers, patients, and/or students.
3. Doctors and scientists who are medical school faculty members are by default great medical student teachers
Teaching is a skill. MD and PhD programs (in the medical sciences) typically do not require courses in education. Most faculty members in medical schools are there because they are physicians who supervise medical students and are thereby required to have a faculty appointment or they are research scientists. This creates quite a large number of faculty members, most of whom have no training in education, and a fair amount who have no interest in teaching medical students. More and more, faculty members have increased requirements in clinical care and research, dramatically limiting their time to teach.
This is harmful because . . . Most medical schools, other than those with a singular mission for education, recruit faculty members for their abilities as a physician or scientist, not for their ability as a teacher. Engaging in faculty development to improve teaching is generally optional and many faculty members who lecture or teach in small groups may have limited training.
4. Clinical training in tertiary academic health centers is better than training in community-based settings
Most medical students, in US allopathic institutions, spend considerable time in tertiary academic health centers and there is a perception that the training is better here. There is more access to specialists, and because interesting cases are referred to tertiary care centers, students there see a much wider breadth of illness.
This is harmful because . . . This is probably the most difficult to explain. Every medical decision -- what is the diagnosis, should I order this test, what is the likely outcome for this patient – relies on probabilities. The likelihood of a specific diagnosis, given the information available, is dependent on the pre-test probability, or the prevalence of that disease in the specific population. The data base of those pre-test probabilities is formed by what you see in medical school and during residency training. So, if you think a rare disease is more common than it actually is, you will diagnose it more often (usually a misdiagnosis), and order unnecessary tests to evaluate that diagnosis (some of which will be false positives). This leads to clinical reasoning errors, misdiagnoses, and overuse of testing—all of which decrease quality and increase cost of care.
Dr. Heidi Chumley
Posted June 19, 2014 09:00 AM