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Invited Commentaries

Learning Alone or Learning Together: Is It Time to Reevaluate Teacher and Learner Responsibilities?

Prober, Charles G. MD; Norden, Justin G. MD, MBA, MPhil

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doi: 10.1097/ACM.0000000000003741
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Abstract

Biomedical knowledge and medical research findings continue to expand at unprecedented speed. For example, the MIT Technology Review noted that by March 16, 2020, over 24,000 coronavirus research papers had been aggregated in one place.1 In parallel, the number of reliable, readily accessible, and searchable repositories of medical facts has proliferated. Therefore, it is necessary and appropriate that medical educators deemphasize the need for memorization while emphasizing learning advanced search skills and the application of knowledge to problem solving and clinical reasoning. Fortunately, over the past few years, rote knowledge acquisition has moved out of the classroom. In many schools, learning has shifted toward opportunities for students to interact with content and classmates in novel ways. While these efforts often have been successful, students’ exaggerated focus on United States Medical Licensing Step 1 scores and rote memorization stifled their impact. For this reason, among others, we welcomed the recent decision to change the reporting of Step 1 scores to pass/fail. We believe that reducing the importance of attaining a high score on Step 1 enhances the opportunity to create a curriculum designed to prepare future physicians for evolving practice demands.

Because we believe that creating the best future physicians requires students and faculty to be physically together to learn essential skills, this new curriculum should emphasize increased student interactions with peers and faculty. A natural venue for these interactions is the classroom. We wrote this paper when in-person instruction was the norm, before the COVID-19 pandemic necessitated social distancing; therefore, our proposal that medical schools require students to attend teaching sessions in the preclinical curriculum is geared to a time when those in-person classes are again possible. Requiring medical students to be in a physical classroom with their peers and faculty should enhance their peer-to-peer interactions and help foster the development of core competencies, including critical decision making, clinical reasoning, and patient-centered care.

Migration From Lectures to Interactive Learning

A 2012 New England Journal of Medicine perspective that one of us (C.G.P.) coauthored with a professor from the Stanford Graduate School of Business argued that lectures are neither an effective nor compelling way to facilitate knowledge acquisition.2 Furthermore, a majority of medical students across the country choose not to attend lectures. Interactive teaching sessions that are focused on scientific discovery, problem solving, and patient stories are more compelling. These sessions attract more students, even when attendance is not required. Since the publication of this article, 8 years ago, the number of medical schools that have markedly reduced lectures as their primary means of preclinical instruction and embraced interactive learning sessions continues to increase. Faculty in these schools have worked to create digital content for their students that replaces lectures. Harvard Medical School has created a digital version of much of their preclinical content and markets this content as HMX courses for which students can earn a certificate.

In some schools, interactive sessions, featuring problem-solving exercises often embedded in clinical vignettes, are used to underscore the relevance of previously watched videos. Two successful examples of this approach at our medical school are our biochemistry and microbiology courses. Over the last several years, these courses have evolved from primarily lecture based to videos complemented by interactive sessions. Students first watch content-dense videos on their own time and then attend interactive sessions to learn from their peers and benefit from the in-person faculty feedback. The number of curriculum hours for both of these courses has not increased, attendance at these interactive sessions—which are optional—exceeded previous attendance at lectures, and student satisfaction substantially increased.3

Revisiting Teacher and Learner Responsibilities

As medical schools embrace more interactive learning opportunities and students reduce their focus on memorization of facts, the time is opportune to reevaluate teacher and learner responsibilities in medical education. Faculty no longer need to directly convey reams of medical facts to the students. Instead, they can guide students toward the most reliable sources of relevant medical information such as textbooks, syllabi, and videos. Teaching effective search strategies will empower students to master how to acquire medical information, while reinforcing how to establish the skills necessary for effective lifelong learning. This pedagogical strategy also will reserve valuable class time for exercises in critical thinking and clinical relevance.

We think that educators have an obligation to design teaching sessions that engage and stimulate learners, capitalize on peer-to-peer discussion, and contribute to the development of critical thinking skills. Faculty can inspire students with the lessons of scientific discovery and engage them in the pursuit of truth through evidence. They can foster student development as future members and leaders of care teams with responsibility for optimizing thoughtful and cost-effective medical care. And faculty can cultivate those attitudes that underpin patient-centered care. In short, medical schools have the responsibility and opportunity to refocus on developing their students’ core competencies.

When one of us (C.G.P.) served as senior associate dean for medical education at Stanford University School of Medicine, lectures were the predominant method for medical schools to convey knowledge; attendance was optional. Many faculty did not appreciate the optional attendance; some expressed the view that students should not be able to pick and choose how they learned. Faculty often expressed disappointment that they were frequently lecturing to a handful of students. Nonetheless, most medical schools across the country did not have attendance requirements for lectures then and still do not in 2020, acknowledging that students are perfectly capable of learning facts on their own.

We believe that student responsibilities must evolve as the medical education paradigm shifts. Medical students retain the responsibility to learn the foundational principles that underpin the science and practice of medicine. These principles should be identified through continued national conversations among medical educators and accreditation organizations and taught at every medical school in the country. The acquisition of the most relevant and critical biomedical facts is the responsibility of our students. The medical academy must be clear on why these facts are critical and how they can be acquired and refreshed. Students must understand that information acquisition is not a static process but rather a lifelong pursuit.

As faculty commit to the development of active learning sessions with peer-to-peer engagement, we believe that attendance policies need to be reassessed. We contend that attendance should be required for sessions designed to teach the process of scientific discovery, critical thinking, value-based care, and a team-based approach to health care delivery. This view is a departure from our thinking of just a few years ago, and it is not based on appeasing faculty. It is based on our obligation to the public to assure that our students are deep thinking, collaborative, and compassionate and use evidence-based approaches.

Comparing and Contrasting Learning Environments

One of us (J.G.N.) recently finished the master of business administration program at the Stanford Graduate School of Business while concurrently completing the MD program. The contrast in teaching between the 2 schools is dramatic, and we believe that it is instructive to examine this contrast. One glaring contrast is that attendance with active participation is mandatory in most classes at the business school. Required attendance in sessions would be a radical departure for most medical schools; we will portray some of the benefits that might accrue if attendance were required.

The power of peer-to-peer learning

Peer-to-peer learning and connection are generally seen as the main reasons to attend a residential business school. Many alumni from our business school claim that the most useful course for their future lives and careers was the course on interpersonal dynamics. This course is an intensive experience where students spend more than 10 hours a week in small groups learning about their leadership styles with educators while interacting with peers. Other examples of successful courses with mandatory attendance include managing difficult conversations, negotiations, and managing growing enterprises. Each of these courses includes student role-playing, and therefore the coursework cannot be done effectively outside of the classroom. Success depends on students challenging their peers and offering direct feedback. Requiring attendance enables students, who may not otherwise have chosen to interact, to form bonds, creating some of the most diverse, interesting, and valuable learning experiences.

We believe that peer-to-peer interactions are critical to the development of team dynamics and team-based knowledge acquisition. When medical students transition from their preclinical education to their clinical rotations, team dynamics and team care will be critical to their ongoing success. Enhanced team building and leadership skills, facilitated by peer interactions, prepare students for their role as part of the interdisciplinary teams that are necessary to assure optimal patient care. In addition, it is widely accepted that embracing diversity and inclusion in general, and in our medical student classes specifically, fosters richer learning experiences. However, we need to create authentic opportunities for the students to learn together to optimize the benefit of the “wisdom of the [diverse] crowd.”4

Opportunity for community building

Required attendance with increased peer-to-peer interaction will help to foster the building of a stronger community. The Stanford Graduate School of Business is an exemplar of this approach—community building is an explicit focus and goal of the business school experience. Requiring attendance creates a strong cohort and bond between students not only during school but also in our graduates’ future careers. Community building has a multitude of positive effects, including giving students a support network and a professional network and enhancing a diverse set of lifelong learning opportunities. We believe that the focus on the results of a graded, high-stakes exam in medical school has weakened community bonds as students have retreated to an isolated learning experience. Increased opportunities for peer interactions through required classes and the creation of a collaborative community also may have a mitigating effect on the isolation many students feel during their time in medical school. Feelings of not belonging undoubtedly contribute to the high prevalence of symptoms of burnout and depression that 30% to 50% of medical students have been experiencing for the last decade across the United States.5

Improved metrics for evaluating students

Evaluations of business school students and medical students differ substantially—highlighting different learning incentives. Business school students do not have standardized national examinations, and their time can thus be focused on interpersonal dynamics and contributions to the learning environment. A substantial component of performance in business school is active participation in class discussions and role-play situations. The comments and insights of students are evaluated according to their contributions to discussion and peer learning. Peer-to-peer evaluations are valued. The incentive for participatory classes aligns with the goal of the course to maximize learning for all. For medical students, the focus on Step 1 has incentivized information retention as the most critical factor for success. As we all recognize the need to emphasize other critical skills for future physicians, we will need to come up with new ways to evaluate student performance.

Mandatory attendance of medical students at interactive teaching sessions would provide the opportunity to evaluate important core competencies such as contribution to the learning environment, peer respect and engagement, critical thinking, problem solving, and clinical reasoning skills. Whereas absolute scores on Step 1 examinations do not foretell future performance on teams and the quality of patient care, many believe that the characteristics observed in group dynamics have predictive inference. As program directors recalibrate the process they use for selecting graduating students, we anticipate that they will value being able to learn from schools how students interact in teams and with peers. Medical schools will be able to report on these interactions throughout their curriculum, not just in clerkships.

Summary

Universal access to rapid and advanced searches of massive sources of medical information has displaced the need for all facts to be held in memory. The relative expertise of physicians should not be based on what they can hold in their heads but rather on how they can use information to solve complex biological and clinical problems. Solving these problems more often than not is an interdisciplinary exercise and requires people to interact for the best learning to take place. A decreased emphasis on standardized test scores as a key metric of medical student performance is a welcome development and creates the space to bring students back into the classroom. Learning from certain practices in business school curricula, medical school educators can refocus on essential skills and connecting with our students.

Competence, communication, and compassion are the skills our patients value most. We hope that an increased focus on the broader competencies of medical education will result from a decreased focus on examination performance. We believe that an evaluation of these competencies will be best achieved by bringing students together in interactive sessions, featuring peer-to-peer engagement. If these venues enhance a physician’s effectiveness, as we hypothesize, we recommend that they be required, not optional, student experiences.

References

1. Hao K. Over 24,000 coronavirus research papers are now available in one place. MIT Technology Review.. https://www.technologyreview.com/2020/03/16/905290/coronavirus-24000-research-papers-available-open-data/. Published March 16, 2020. Accessed March 20, 2020.
2. Prober CG, Heath C. Lecture halls without lectures—A proposal for medical education. NEJM. 2012;366:1657–1659.
3. Chen SF, Deitz J, Batten J, et al. A multi-school collaboration to define core content and design flexible educational components for a foundational medical school course: Implications for national curriculum reform. Acad Med. 2019;94:819–825.
4. Surowiecki J. The Wisdom of Crowds. 2004. New York, NY: Doubleday
5. Roberts LW. Understanding depression and distress among medical students. JAMA. 2010;304:1231–1233.
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