The Changing Man

At first, reluctantly. When I entered academic pathology in the US in the 1960s/1970s, the common adage among the key thought leaders at the time was that those who can’t do research do hospital pathology, and those who can’t do that, teach. Teaching was relegated to the lowest branches of the academic tree; even popular teachers who did not do any research were considered “losers” by their peers. So it took some courage to become a “professional teacher.”

I soon became aware of the negative connotation assigned to full time teaching. I was genuinely interested in research, though, so I applied for grants and luckily managed to establish an NIH-funded laboratory, which I ran for 25 years in Philadelphia. I now have over 300 published papers in peer reviewed journals, over 12,000 citations and an" h factor" of 50 and some 30 books to my credit. In spite of these achievements and my numerous academic qualifications, some of my detractors insist on calling me “just a teacher.” There is no point citing my official abbreviated titles MD, MSc, PhD ,Dr h.c., FAC, which in real-life are more often used by lawyers in court to prove my legal qualifications than for establishing my academic credentials. At my age of 75, though, I don’t care how they label me anymore. As I was taught early in my career, all the accolades are sham unless they are garnered by an occasional derogatory comment. If I never believed in a 100 percent vote of confidence – the norm for the voting communist parliament in Titoist Yugoslavia of my youth – how could I ever believe that all students would like me unconditionally and give me 100 percent approval? When it comes to teaching, it’s worth paraphrasing Henry James, who said, "We do what we can, we give what we have and the rest is madness of the art."

At the beginning of my career I was supposed to be a Flexnerian “tripartite” academician, spending one-third of my time in hospital work, one-third in research and one-third teaching. For the first dozen years of my career this approach worked more or less quite well, although even then I was spending more time with residents and research graduate students than medical students.

My major switch to medical education occurred in 1986 after I joined the staff of the Jefferson Medical College in Philadelphia, as a member of a 50+member team headed by Emanuel Rubin, where I took charge of the undergraduate student medical education. My first task was to reorganize the teaching of pathology and to improve the results of the students on the Pathology part of USMLE1 (National US Medical Licencing Examination), which were in the lower 20^th percentile at the time. In less than a year I managed to raise scores to the 90^th percentile and they remained that high during my tenure there.

By full engagement, team work and by motivating students for active learning. My proclaimed motto, was: We do not teach you! We help you learn! By stimulating students to excel and work hard from day one of the course we improved the performance of the top scoring students so that at least 20 percent of them were in the national top 10 percentile. We published our data and described “how we did it”, hoping that others will benefit from our experience (1). Many of our students liked pathology so much that they stayed with us as post-sophomore fellows working in the hospital as junior residents for one year.

We enroled six volunteers from the Medical School class that took our "reformed" course, and they helped us to teach and to boost the visibility of pathology – and it became one of the largest post-sophomore programs in the country. Many of those students chose pathology as their lifetime career. We were elated by our success and my work was recognized by the Golden Apple Award for Teaching and later by the Tom Clark Award for Teaching Excellence (2)!

Yes. I was lucky to be a faculty member of Jefferson Medical College for eight years. Jefferson is a unique medical school devoted to long-term studies of medical education and practice. Joseph Gonnella, who was the Dean of the College at that time was also the founder and once Director of the Department for Medical Education at Jefferson. Fully staffed with MD and PhD scientists that Department has produced some of the seminal publications pertaining to medical education and medical practice. I was included in their research team and during my tenure I published some 10 papers on medical education. I also learned a lot about the theory and practice of medical education.

Patriotism. I am from Croatia and I wanted to help my colleagues establish a pathology course in English. Many of the richest European countries do not have enough physicians, and there is a need for more doctors. But, most European medical schools have a numerus clausus, and many applicants for medical schools are never admitted. These young man and women are looking for medical school positions abroad and are willing to pay tuition to take medical courses in English in countries like Slovakia, Hungary or Poland. Croatia has two medical schools (University of Zagreb and University of Split) offering such courses. I have taught pathology in English in both Croatian medical schools and I can assert that these ex-pat students are as good as their peers in typical US Medical Schools or, for that matter, Croatian student taking the same courses in their native tongue.

The need for young doctors exceeds the current supply and, as long as such a need exists, there will be ways of producing new doctors through these supplementary courses. In the US there is also a great need for new doctors, many of whom are schooled in the private Medical Schools in the Caribbean islands or in Europe. I have personally worked with young Caribbean schooled US physicians and I feel that most of them are more than qualified to practice medicine in the US or elsewhere. The same probably holds true for the physicians graduating from the various courses attached to the regular national European medical schools. Nevertheless, I am a bit appalled that the European Union has not yet developed some rules and regulations for controlling these English-taught schools and reassuring the public that the graduates of these schools have knowledge equivalent to their peers graduating from the “regular” medical schools. I have discussed this with some of my European colleagues, but nobody wants to discuss that issue. I am not a control freak, but some form of EU legislation would give an official stamp of approval to this type of medical school educational.

We need to move away from lectures ex cathedra and teach in small discussion groups. Case-based learning is used in our residency programs and there’s no good reason why it cannot be applied to all medical courses, including pathology.

Our trainees serve as our apprentices and that type of tutorial teaching of pathology has proven to be the most popular model in the US. As residents advance they also assume teaching roles, and I believe that’s the best way of learning. We supplement our teaching with formal lectures, and some of us have even prepared formal, commercially-available courses for pathologists in training. I am very proud of the 22 comprehensive courses, covering the entire human pathology, that I have helped develop (3). These courses are given by the best US teachers I could recruit. Their lectures are much better prepared than those given locally to our residents on an ad hoc basis. They save time for everybody— the faculty and the residents. Young pathologist in training love them, reflecting the fact that the new generation uses different learning techniques compared with the “older guys,” who take such course begrudgingly for CME credits. As the Latin saying goes “tempora mutantur” (times change) and we better adjust to our trainees’ needs before it’s too late.

I also believe that good medical teaching must include other professionals, such as educational psychologists, psychometricians and learning experts. I firmly believe that medical education is in need of major change, but the chances of change happening any time soon are slim. Inertia and self-complacency are deeply rooted in most medical education and, for the time being, traditionalists will be in charge ensuring that nothing really changes.

A few years ago I gave a presentation entitled “Is it possible to practice medicine without teaching?” The short answer is emphatically: No. For a longer answer you may consult my web-based presentation of the same title (4). I also think that we need to further develop computer-based learning. Today, we have this incredibly powerful technology and all we do is use it as a substitute for the pencil and paper to complete multiple choice exams! We should develop computer-based national exams which would test students’ real knowledge. The other day, my teenage grandchildren told me, “If you are not on the web you do not exist.” I fully agree. In the 1967 film The Graduate, the protagonist was given the advice to go into "plastics". So today my advice would be, go "in silico."

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