As Education Changes, We Must Too

Medical undergraduate courses have evolved from tedious exercises in intensive rote learning into well-planned conversions of raw school leavers, or graduates from other programs, into doctors well-prepared for practice. In some areas, the evolution has occurred very rapidly, but elsewhere progress has been glacial – or even non-existent. To some degree, a lack of resources has hampered progress, but that is often not the issue. Ironically, advanced medical education ideas are often enthusiastically embraced by countries that are struggling with poverty in the developing world, while the same ideas are resisted with equal enthusiasm and impressive tenacity in countries with vast wealth! It’s time for a change of mindset. Here’s why.

Doctors work by applying appropriate sets of knowledge items – often called “scripts” – even if they are unaware that they are doing so. For instance, a doctor dealing with a patient with acute abdominal pain will have a mental script based on his or her knowledge of abdominal anatomy, the pathophysiology of inflammation and ischemia, human psychology, and much more – including, especially, previous experience of such cases – to aid initial diagnostic formulation. They will use other “scripts” to determine investigation and management. In essence, doctors call upon their training in many different disciplines to reach a final diagnosis. Given that a doctor’s approach to determining a diagnosis integrates knowledge of multiple disciplines, surely to teach these disciplines individually during their education is inefficient and not reflective of real life.

In a bid to address this, various integrated teaching courses have been developed. Many of these use some form of case-based or problem-based curriculum – in fact, there are so many forms that a taxonomy of methods exists! What they all share in common is that learning is driven (usually) by fictional cases about clinical problems, presented within authentic scenarios, and selected to reflect the breadth of a curriculum. Because an authentic scenario typically crosses many traditional disciplines, no single discipline dominates. These scenarios, in most problem-based curricula, are used to encourage students to develop and fulfil their own learning agendas; tutors guide rather than teach.

Teaching within an integrated curriculum has major challenges though, especially for disciplines not seen as central by practitioners of the larger specialties such as medicine and surgery. Where there are no individual courses in pathology, there is a very real risk that such teaching can disappear from the curriculum altogether, and laboratory doctors will be in danger of having no opportunity to meet students.

The latter is a big problem, because research shows that the most potent factor in students’ choice of specialty is identification with a positive and inspiring role model – and if you don’t get to teach or tutor students, you can never become a role model able to recruit them as your potential successors. Many pathologists in the UK, including very senior members of the Royal College of Pathologists, responded with hostility to the pioneers who developed such integrative teaching courses.

Recognizing that a return to formal “-ologies” was simply not going to happen, some of us engaged with the new direction in tutoring instead of reacting against it; nothing else was likely to address the looming problem. Becoming involved with the development and design of integrated courses has allowed us to introduce relevant elements of histopathology, microbiology, hematology, and so on. It also allowed deletion of copious elements, often of basic sciences, that had no realistic application in the near future. For instance, I was able to ensure that the biochemistry being learned by students was relevant to understanding how bodies worked, and how to investigate and repair them when they don’t work; the products of arcane research were ruthlessly eliminated.

As well as designing cues to learning about pathology and what it achieves, there are opportunities for pathologists to tutor and lecture: because no single case is limited to a single discipline, there is no requirement for a tutor to be a specialist in the material being learned. However, some understanding of the general principles is an advantage – and the breadth of knowledge required by a good pathologist makes for a good tutor. If you’re interested in getting involved in similar teaching programs, you should go for it. After all, by judiciously demonstrating what a fascinating life a pathologist leads, you may just plant the seed in the mind of some perceptive young person that you are practicing medicine in a way they would like to emulate. One of my colleagues routinely asks candidates wishing to become histopathologists to explain their choice, and I’m gratified to learn that many cite my teaching, and my obvious enthusiasm for my discipline.