I spent the majority of last week at the Association of American Medical Colleges. This was my first time attending the majority of the meeting and it did not disappoint. While there is lore that some authors are not good speakers, this was definitely not the case with Malcolm Gladwell. Using vignettes ranging from the Civil War to the downfall of Bears Stern and recent financial crisis, he eloquently described what happens when ‘experts’ fail. Experts fail due to miscalibration, not incompetence. Miscalibration results from overconfidence when one perceives they have perfect information. This is certainly true in medicine, in which overconfidence can lead to diagnostic error through early closure.
While I was still mulling over expert failure, I attended a very interesting session titled “Flexner, Freedom, and the Way Forward” delivered by Steve Kanter, editor of Academic Medicine and Dean of the University of Pittsburgh. Drawing from the educational pedagogy of Brazilian Paulo Freire, he articulated the need to go from the traditional medical education that is fundamentally oppressive, inhibits critical thinking, and rewards conformity to one that promotes intellectual inquiry, the freedom to explore ideas, and imagination. Unfortunately, the current “deficit” model focuses on students as the major problem, as opposed to environment or instructional practices, and is characterized by the famous “P=MD” promulgated in medical schools today. The increasing emphasis on student unprofessionalism, with little attention on altering the environment or examining the role models – positive or negative- that students interact with is another example of the deficit model.
So, how do we move to a generative model, which encourages more imagination, creativity, and freedom? Interestingly, one of Kanter’s answers was through the cultivation of scholarly projects, something that he has championed at the University of Pittsburgh. This was particularly interesting given the explosive growth in schools that now offer scholarly concentrations, including our own. During an early morning breakfast meeting of schools with ‘scholarly concentrations’, I wondered if we would reach a Gladwell ‘a tipping point’ where medical school ‘majors’ would become commonplace or whether these would remain a niche for select schools.
In addition to thinking about how to move forward, it’s also important to think about how we ended up with this model if it is not desirable? Is it possible that expert medical educators failed to recognize the importance of critical thinking? Well, a more plausible explanation is conformity is actually desirable. After all, few patients are looking for ‘creative imaginative doctors’ (often synonymous with quackery). Instead, doctors are rewarded for ‘standard of care’ and following ‘evidence-based standards.’ Although creativity and imagination are not rewarded in medical practice, it is certainly needed in medical education. On this centennial of the Flexner report, there were plenty of reminders at AAMC that we still have the same problems that plagued medical educators 100 years ago. Reasons for lack of progress in this area include inertia, lack of funding, and the perverse incentives academic health centers that detract from the teaching mission.
But, this begs the question, is medical education ready for creativity and freedom? Interestingly, while the “mHealth” or mobile health summit was showcasing the latest technological innovations and advances just down the road in DC, AAMC sessions on social media and medical education focused on the fears associated with increasing use of social media among medical trainees. When full-scale institutional bans were mentioned, students highlighted how this may inadvertently result in a backlash, popularizing these technologies or the creation of an underground. In the words of one student (per @MotherInMedicine) “You trust us to care for patients, but not to post on Facebook.” Interestingly, medical educators weren’t the only group thinking about social media and professionalism. At the same time, the AMA issued its new guidelines for social media, aimed at helping physicians cultivate a positive professional online presence without jeopardizing the doctor-patient relationship. While social media use in medical education continues to be debated, the meeting was a powerful reminder that we need to consider the future practice of medicine in training the physicians of tomorrow. While we cannot ‘see’ exactly what the future holds, ignoring it entirely would certainly be oppressive and an expert failure.
–Vineet Arora, MD