It’s spring, 2008. I’m perched on a cheap plastic chair at a wobbly fold-out desk in the university sports hall, coat zipped to the chin. All 300 students from my class are here, spaced at carefully measured one metre intervals. The only sounds, however, are the scratch of pencils on paper, the ponderous footsteps of invigilators and the occasional sob.
We’re sitting our “intermediates”: a gruelling nine days of written exams whose subject matter is the entire curriculum of our three preclinical years. I’m doing ok so far – I’ve matched HLA alleles with associated disease phenotypes, detailed the differences between subtypes of renal tubular acidosis, described the principle means by which Pseudomonas species evade the host immune system. Then I turn the first page of the ophthalmology section and let out a groan as I read: “What is the wavelength of green light?”
When my medical school was founded, the ability to transform oneself into a walking encyclopaedia through the rote learning of entire textbooks would have been a huge asset. Scientific texts were terrifically expensive and access to the contents of the university library during undergraduate studies was, for most, a once-in-a-lifetime opportunity. The more facts a student could assimilate before graduation, the better equipped they would be to serve their community after catching the pony trap home.
Fast forward a couple of centuries, however, and I’m thinking this mindset may have run its course. Like every other student in that exam, I have a 3G-enabled smartphone in my rucksack at the back of the hall that puts an unfathomable body of knowledge at my fingertips. Should the battery run dead when I’m out on the wards, I can hop on the nearest computer. Should the hospital’s internet connection somehow fail, I can reach for my perfectly pocket- sized Oxford Handbook of Clinical Medicine. My medical education seems to be based on the premise that access to knowledge is the principle barrier to good clinical practice, whereas the reality of 21st century healthcare is almost the reverse. To borrow the somewhat harsh language of Gorovitz and MacIntyre, the challenge of ineptitude has superseded that of ignorance, but my medical school doesn’t seem have to have noticed.
Things are beginning to change. More store is being set by the ability to critically appraise and less by the capacity to memorise. The importance of good communication skills has been widely acknowledged. Simulation-based training – the most effective pedagogical route to adaptive expertise – is employed routinely at many institutions.
But there’s still a long way to go to catch up with the present, let alone to make the leap from reactive to pro-active education. I routinely find that house officers (interns) can manually calculate the cardiac axis from a 12 lead ECG (something an app on their phones could do for them in an instant) but that they can’t operate the external pacing function on a defibrillator. I sometimes wonder if the entire medical school syllabus should be divided into “things you will have time to look up” and “things you really do need to know by heart”.
As a clinician and data scientist, I’m convinced that the healthcare landscape will change at least as much over the next 30 years as it has over the last 30, and probably rather more. The complexity of 21st century medicine has outstripped our ability to manage it manually and system-wide adoption of intelligent computing is no longer a luxury but a necessity. As policymakers come to this conclusion, so must educators.
If medical students are to understand the AI systems that will inform their day-to-day decision making, existing parts of the curriculum will need to be cut in favour of data science modules. Some prescient institutions are already doing this, and you can be sure that their graduates will dictate the future of healthcare over the next couple of decades.
The type of person we recruit into the profession should also receive careful thought. The hippocampus- heavy students who could recite Merck by heart are ill-suited to a world where most questions can be answered in just a few clicks. The clinician of the future will be an interlocutor between patients and intelligent machines, which will require the same scientific reasoning and human empathy that we purport to value in our students at the moment, but perhaps in very different proportions.
Finally, the way we conduct assessments may need a major overhaul. Confiscating phones and sending students into an exam hall to answer questions from memory makes little sense in a profession that relies heavily upon the ability to marshal a wide range of resources (online and otherwise) to solve complex problems. And as for the wavelength of green light? Google it
Dr. Rob Brisk is a Clinical Research Fellow at Craigavon Area Hospital, Belfast