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Teaching in medical school: Establishing quality standards

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

doctors and students talkingHaving just had three weeks off for winter break, I've spent some time thinking about my medical school experience. And in reflecting on my first several months of rotations, I realized that my most salient memories are not based on complex medical issues or patient interactions (although I have had one or two memorable encounters). Instead, they're largely shaped by the interns, residents, and attendings whom I've worked with.

This is perhaps not an interesting revelation. Of course the people who we work with influence our experience. However, the implications of this statement are often overlooked in medicine.

Standardization is a hallmark of American medical education. While every school has distinctive curricular features, all of them cover the same core content and require similar clerkships. We use standardized patients to learn clinical skills, use textbooks that teach the same pathophysiology of disease and use the same set of resources to study for Step 1 of the U.S. Medical Licensing Examination. Medical students have many shared experiences.

The goal of such standardization is to ensure that all students achieve a threshold level of knowledge and skill that will allow us to be competent doctors. But amidst all the efforts to standardize curricula, information and experiences are ultimately conveyed by teachers. And maintaining high teaching standards is often de-prioritized, especially on rotations.

Every resident and attending takes a different approach to students. Some encourage us to be active and take on as much responsibility as possible. Others prefer students to have a more passive role. One resident carved out time to walk me through interesting medical cases nearly every day. Another told me that she didn't have time for my questions.

As a result, two medical students might have vastly different experiences even if they are on the same rotation at the same institution at the same time.

This has several consequences. On an individual level, the quality of teaching can dramatically alter a student's perspective on a field. We are often advised to make decisions about a specialty based on our rotation experience. But using a one or two month experience that can be enhanced or soured by a single individual is a tenuous way to make a career decision.

On a broader level, variable teaching means that students may not learn certain topics well and detracts from the effort to guarantee high quality medical education.

People in medicine often dismiss this concern as an intractable problem (e.g. "Mentors in any profession will be variable and you can't standardize their approach") or an insignificant one ("Med students complain too much. We had it tougher back in my day").

Regardless, I believe two changes could help improve the quality of teaching during rotations. First, expectations should be clearly established for students and instructors (at every level). On some teams, multiple days would pass before the attending, resident, interns, and students all understood each other's roles and responsibilities, which harmed both the quality of teaching and patient care. Institutions should invest time and resources to standardize those expectations.

Second, the training process should place a greater emphasis on teaching skill in evaluating and rewarding trainees. Medical education heavily prioritizes clinical skill and research (I previously wrote about research in medical school). Meanwhile, teaching ability is appreciated but rarely expected. That should change. Students should develop as teachers while still in school (Stanford does a great job by encouraging students to serve as TAs). Teaching is a critical skill for residents and attendings but is often treated as an incidental obligation.

It's worth noting that by and large, I have had excellent teachers on my clerkships. Thanks to their efforts, I have learned a tremendous amount in the past few months and will continue to do so moving forward. Even so, many opportunities remain to improve the quality of teaching in medical school.

Akhilesh Pathipati is a third-year medical student at Stanford. He is interested in issues in health-care delivery. 

Photo from MD Admissions site

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