I confess that I did not know Dr. Del Harnish, but I have gained an understanding of him from the written words and respect of his colleagues. Dr. Harnish was a true believer in student-centred learning, and he lived it through his work in the BHSc program at McMaster. In the commentaries, it is clear that Dr. Harnish aimed to prepare his students for the uncertainty, troubles, and opportunities that were so aptly outlined in Teaching as a Subversive Activity, written almost 50 years ago (Postman & Weingartner, 1969). This led me to ask myself, “are we in medical education doing enough to prepare future physicians for the uncertainty they will face in the future?”
Although the field of medicine seems to be fully alive with uncertainty, I was blind to this concept for many of my first years teaching physiology at a medical school. My first interaction with this concept (although I did not recognize it at the time) took place in the classroom when I observed a very successful nephrologist and hypertension specialist respond “I don’t know” to a student question. Up until that moment, I don’t believe that I had seen any faculty member make such a statement in front of medical students—at the time, most of us viewed this type of uncertainty as chum in the water for an upcoming feeding frenzy. Despite my presumptions, the circling sharks did not appear. Although I would not have termed it “uncertainty” at the time, I learned as a junior faculty member that it was okay to say “I don’t know”.
My first formal introduction to the world of uncertainty took place at a conference where Dr. Andrew Olsen spoke about the topic. In his presentation, he spoke about a young female patient who had right upper quadrant pain. Her parents took her to several physicians and the running diagnosis of a gallstone was considered. Ultrasounds were ordered to confirm the presence of stones, but no stones were visible. All other symptoms were supportive of this diagnosis, and the surgeons pushed ahead despite emptiness in the gall bladder; they were certain she needed surgery. During the surgery, the patient had a severe hemorrhage that the surgeons could not control, and she died. She was less than 18 years of age. As a new father of two young girls, this story hit home. This death resulted from the inability to say “I don’t know what is wrong” and the inability to recognize when one must slow down in clinical decision making. As patients, we hope that our doctor or our child’s doctor is confident. However, confidence can be tenuous in in the face of uncertainty.
The challenge is how to teach our medical students to realize the uncertainties that percolate through medicine on a daily basis. I teach early in the medical school curriculum, before any patient care exposure and where diseases are presented in a virtual case on a computer monitor. Most of our curriculum is still focused on content delivery rather than developing thought processes. The primary method of assessment at my school, and many others, is the United States Medical Licensing Exam-like multiple choice question; this prepares students for Step 1 of the exam, which is one of the most influential determinants of their residency application. At least one major issue arises from this approach—this exam tests only one domain, knowledge. There is little uncertainty because the answer is either wrong or right. Where, then, do students learn about other important domains such as critical thinking or problem solving? In the current medical school environment where we feel as though we must cover every disease for the student, I would argue that the answer lies in finding alternative ways to promote student-centred learning.
A quote from a colleague of mine, an educational psychologist, has served as my foundation for teaching. She states simply that “if you as a faculty are working harder in the classroom than your students, they are probably not learning.” (Note, this does not include the preparation work done behind the scenes!). My feeling is that lecture is by far the most common pedagogy occurring in medical schools today. The standard lecture (faculty-centred) is the extreme example of the faculty doing the majority of work. Students are not testing their mental models of a process or struggling with a concept. As stated earlier, faculty tend to retreat to this method, driven by the need to provide content and the perception that the standard lecture is the most efficient way to do this. The ever-expanding content in the field of medicine also severely limits the opportunities for student-centred learning and any ability to introduce uncertainty.
So, how do we transition to student-centred learning in medical education? Interestingly, I believe that faculty will be forced to transition if they haven’t already. Not by Deans, accrediting bodies, or other administration, but by the numerous resources that are quickly becoming available for students. Currently, there are numerous companies that are able to deliver content in presentations that are high quality, efficient (student can view in 2x mode), and provide recall or USMLE-like questions relevant to the content. Many faculty feel threatened, viewing these resources as their “replacement”. I feel that these external resources will actually allow faculty more time to focus on higher order thinking (what educator doesn’t desire this?) or clinical reasoning. These resources should also provide faculty time to highlight their experience and show the true uncertainties that their job deals with on an everyday basis. Activities should be developed that have more than one right answer. Let students realize that most choices we make in our lives and careers do not always have “right” answers.
Ultimately, we need to realize that faculty are not the “gate keepers” of knowledge as they were in the past. Medical educators must shift the responsibility of learning to the learner. To do this, we must have confidence that the students will be able to “get” something without us feeling the need to tell them everything. Let students use more efficient content delivery methods to buy them time. This frees time for faculty to share our greatest asset, experience. Who knows? This just might give students the time to explore new, improved methods for optimizing patient care, which should be a goal for all.
Postman, N. & Weingartner. (1969). Teaching as a Subversive Activity. New York, NY: Delta Publishing Co., Inc.