Wilkes, Michael S. MD, PhD; Hoffman, Jerome R. MA, MD; Slavin, Stuart J. MD, MEd; Usatine, Richard P. MD
Just over 20 years ago, the UCLA School of Medicine embarked on a bold curriculum initiative: the creation of a comprehensive, longitudinal, multidisciplinary “Doctoring” program that would complement the traditional curriculum and would span all four years of medical school.1,2 At the time Doctoring was introduced, in 1992, the medical school’s curriculum focused primarily on the delivery of vast amounts of factual information in the basic sciences and took a detailed, disease-specific (rather than patient-centered) approach to clinical medicine. In Doctoring, we proposed to teach around the “hidden” curriculum and cover content that was typically addressed superficially, if at all. We believed that doctors in training, regardless of their ultimate specialty choice, need to acquire a new and different skill set in order to be prepared to engage appropriately with patients, families, and communities.
Although we do believe, two decades later, that Doctoring has taught important skills to large numbers of students—and has had some impact on the larger culture of medical education—its full promise remains unfulfilled. In this commentary, we reflect on the challenges we faced when first creating and implementing the program, and we look forward to opportunities to improve and overcome barriers in the next generation of Doctoring.
Reflections on the Four-Year Doctoring Program
Overview of the program
The Doctoring program, which has been described in detail elsewhere,1–9 includes content regarding a wide variety of psychosocial issues (including substance abuse, domestic violence, and mental health) as well as training in essential communication and reasoning skills—areas that the traditional curriculum ignored. It stresses the importance of learning to communicate effectively, especially in difficult situations such as those in which there is risk, uncertainty, conflict, futility, or bad news to give. Doctoring also teaches students how to understand and apply evidence, incorporating the concepts of diagnostic and therapeutic reasoning in the context of actual clinical cases, rather than as abstract disciplines that are only tangentially related to patient care. In addition, it addresses larger socioeconomic issues, including health care disparities, cost-effectiveness, and ethics (e.g., conflict of interest in interactions with industry; conducting clinical research).3–6 Doctoring attempts to integrate public health and social science perspectives into a curriculum that explicitly asks medical students to think about medicine’s social contract with society and stresses to them the need for patient-centered, evidence-based care.7–9
Doctoring is taught across all four years of medical school, in weekly meetings of small groups of students under the guidance of a faculty physician and a mental health clinician.10 Each session is interactive and involves a scripted clinical scenario where one or more standardized patient(s) presents for care, and one of the students (on a rotating basis) is charged with addressing the patient’s problem in front of the entire group. The group, in turn, is expected to provide feedback to the session’s lead student, as well as to ask questions and engage in discussion about the key issues that the case is designed to raise.11 Thus, over the course of each academic year, students are exposed to a standardized curriculum based on the panel of “patients” they “care for” as a group.
We believed it was critical that the Doctoring program be longitudinal so that the information and skills learned would be reinforced rather than forgotten and become an integral part of the overall medical education endeavor. Of the many practical difficulties related to creating and implementing such a comprehensive new program, the greatest barriers, by far, were cultural.12 These included faculty opposition to taking time from the established curriculum (especially during the clinical years, when students would need to leave their clerkships to attend Doctoring sessions), a widespread belief that teaching was delivered most efficiently by lectures, discomfort with moving away from a strictly biomedical focus, skepticism about the utility of standardized patients when students were already seeing “real patients,” and faculty resistance to changing the apprentice-based clinical curriculum that had “worked for them.”13
Finally, there was also resistance from students, who had been chosen for medical school, following fierce competition, primarily because of their ability to learn large amounts of facts and who were intensely aware of the mass of new and different information that they would ultimately need to learn. Many students were uncomfortable with an approach that not only declined to provide them with a compendium of truths on which they could rely but also required them to cultivate skills that had nothing to do with the information covered in their textbooks and board exams, to work through problems for themselves, and even to question much of what they had been taught.
Looking Ahead: The Next Generation of Doctoring
We have no doubt that many aspects of Doctoring and similar programs can and will be improved on by other educators. Opportunities for improvement include continuing to endeavor to make the teaching material more stimulating, enhancing the use of technology (e.g., Web-based interactive programs, simulation curricula), improving methods for assessing clinical skills, and adopting innovative approaches such as individualized student action plans that incorporate personal feedback from faculty. In addition, although we made great efforts to include nonphysician teachers (particularly psychologists, as well as nurses and social workers) in the program faculty, there is much room for improved input from these and other disciplines (especially, perhaps, experts in public health and health care economics).
We strongly believe that the use of standardized patients working off scripted case scenarios offers enormous advantages for student learning, by ensuring that specific issues can be raised—and addressed—in a safe environment, where mistakes that students inevitably make will not hurt real patients or the student’s development. However, there may also be some role for the use of “real patients,” as some students desire. Similarly, there may be an important role to be played by laypeople, both as observers and as commentators, and even as faculty. In addition, Doctoring and similar programs can do more to promote student wellness, self-care, and lifelong learning.
A list like this reflects only a few of many possible areas in which the critical concepts of Doctoring could perhaps be taught more effectively. However, we do not believe that any such improvements are fundamental to ensuring that Doctoring and similar programs will have a meaningful impact on students’ overall education, as well as the larger culture of medicine, in the future. Programs that not only attempt to change the content of what students learn but also encourage students to develop the ability to think critically cannot truly be successful unless and until that larger medical culture also changes. In some sense, this is a catch-22 situation: Programs like Doctoring are designed to prompt students and faculty to question fundamental aspects of the way medicine is taught, learned, and practiced, but, at the same time, important changes cannot occur until some of the forces that shape that larger culture understand and agree that there is a need for change.
When we first created Doctoring at UCLA, we were careful to negotiate with the dean for time for a longitudinal program running through all the years of medical school,1 in order to avoid the problems that had plagued many previous attempts to teach important concepts such as doctor–patient communication or medical ethics via stand-alone courses. These included students forgetting or ignoring what they had learned in such courses, and seeing behaviors modeled during clinical rotations that were antagonistic to the ideas that they had learned in the classroom.
Ironically, the same problems that these stand-alone courses faced continue to plague Doctoring. Although the program does continue throughout all four years of medical school, it has not, in a fundamental sense, been truly integrated into the larger curriculum. Below, we offer our recommendations for ways to accomplish this by overcoming faculty resistance, increasing administrative support, and changing the philosophy behind the selection of medical students.
Overcoming faculty resistance
Faculty resistance to the concepts promoted by programs like Doctoring is multifaceted, and key aspects of such resistance are unlikely to change or be overcome unless and until there are also changes in the overall culture at medical training programs. Perhaps the easiest issue to address is the absence of incentives for faculty participation. Nonadministrative faculty are typically paid according to the income they generate through clinical revenue and/or research grants, and extremely few resources are devoted to pay for teaching. There seems to be a near-universal assumption that individual faculty members teach because they believe it is important; although (fortunately) there is a great deal of truth to this, this allows medical school administrators to set aside few dollars to incentivize teaching. Recognizing that teaching in programs like Doctoring provides enormous service to the institution, and offering tangible benefits (including salary support) for participation, would go a long way toward facilitating the recruitment of outstanding teachers. It would be equally important to value the contributions of teachers as part of the promotion process.14,15
Changing some of the fundamental beliefs held by some faculty may be more difficult. Medical education has traditionally been delivered in a hierarchical fashion: Because it is typically assumed that the attainment of knowledge and wisdom is simply a matter of spending time memorizing appropriate details, it is not surprising that faculty are never expected to learn from residents, or residents from students. The dominant medical culture therefore discourages anyone from challenging someone more senior and rejects even the possibility that a more junior person can be correct while a more senior person is not. Because few faculty have themselves learned in an environment where they were asked to challenge conventional wisdom or were encouraged to think critically, it is not surprising that they look askance, and even feel threatened, when such ideas and behaviors are promoted. Similarly, faculty response to student concerns about the many abuses of traditional medical training seems to be reminiscent of the responses of people who have undergone any type of hazing ritual: “I got through it just fine.” Complaints by the current generation of students are often greeted as though they simply represent a lack of fortitude and/or an unwillingness to work hard or stand up to pressure.
Perhaps the best hope for overcoming these sources of resistance is the development of a new generation of teachers who have gone through programs like Doctoring and support the concepts it espouses.16 This may, however, require more than simply the passage of time. Given that faculty are selected and promoted on the basis of activities different from those emphasized in Doctoring, changes in faculty recruitment and promotion criteria may be needed.
Increasing administrative support
It is one thing to agree that it is important for students to learn about communication, ethics, or patient-centered care; it is quite another to provide adequate time, space, resources, salaries, and academic rewards for teaching in these domains. Positive incentives are not sufficient to ensure the success of programs like Doctoring, however. Administrators must also ensure that there are real consequences for faculty and residents who sabotage these programs by, for example, making it uncomfortable for students to prioritize their work in Doctoring or making it difficult for them to leave the wards to attend the assigned classes.
Changing the philosophy of student selection
Medical students are quite bright and extremely successful at accomplishing tasks to which they have been assigned—that is how they survived the fierce competition to attain their spots in medical school. As undergraduates, few of them majored in nonscience fields such as history or literature, disciplines in which they might have been expected to develop skills like asking difficult questions and critiquing received wisdom. Medical students are typically chosen for their demonstrated capacity to memorize great amounts of information—which is, in fact, an ability they will need in order to attain basic competence as doctors. But unlike other graduate students, and regardless of their prior training, they arrive at medical school essentially as beginners. It is not surprising, therefore, that they are comfortable when asked to use these same proven and familiar learning skills, and uncomfortable when asked to use skills, like critical thinking, that are mostly unfamiliar. Furthermore, if incentives drive learning, as long as honors nominations and residency selection rely on the traditional criteria of standardized test performance and “fitting in” on clinical services (by conforming to accepted behaviors and avoiding conflict or confrontation), those will remain the currencies that matter.
The key elements of Doctoring and similar curricula are conspicuously absent from such measures of success. Furthermore, in the presence of a dominant culture that often chastises students for not knowing facts and that even encourages them (subliminally, at least) to pretend to know when they do not, many students become confused when programs like Doctoring attempt to stand this paradigm on its head and ask them to value critical thinking over efficient learning.
We have no interest in disparaging today’s medical students, whose talents and intelligence are manifest. We understand that there is no ideal way in which to choose, from the large numbers of excellent candidates, those students who will best succeed at becoming the type of physicians envisioned by programs like Doctoring. Nevertheless, we believe that an approach that places less value on grades or standardized test scores and more value on a passionate commitment to serving the community and individual patients, on an ability to communicate, and on critical reasoning skills (even if these are difficult to measure) might well go a long way toward recruiting students who will thrive in a changed medical culture.
Over the past two decades, Doctoring and similar programs have had an impact on medical education by teaching content and skills that are often overlooked in traditional medical school curricula. For such programs truly to affect the larger culture of medicine, however, prior or simultaneous changes are required across multiple levels of the larger medical school enterprise. These include changes in the philosophy behind the selection of medical students, the provision of far greater resources, support for course faculty, and altered incentives for medical school faculty. In addition, there must be a commitment by medical school administrations to ensure that the larger curriculum does not subvert what Doctoring-type programs are trying to accomplish. Until major cultural and structural barriers are overcome and the values that these programs attempt to engender become the primary values of the larger culture they seek to change, Doctoring and like programs will continue in fundamental ways to function outside the dominant culture of medicine.
Other disclosures: None.
Ethical approval: Not applicable.
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