I started medical school in 1975. That’s 47 years ago and a lot has changed since then. The way we practice medicine has changed, but the way we educate doctors is much the same. Is that a good thing or a bad thing? Let’s talk about it.
Robert Pearl, M.D. says a lot needs to change. In a series called Breaking the Rules of Healthcare, Dr. Pearl challenges conventional thinking about medicine in several areas, including medical education. Today we’ll talk about what he says about the way we choose doctors – and medical students.
Dr. Pearl says all doctors adhere to two different sets of rules. There are the written rules, covering everything from human anatomy and physiology to the current law and regulations that govern the profession. Then there are the unwritten rules, which dictate the “right way” to act. These rules, he says, which heavily influence clinician behavior, aren’t taught in textbooks or lecture halls. They are observed and subconsciously absorbed by medical students and young doctors whilst trying to learn the ropes and earn the respect of physician leaders.
He says most of healthcare’s unwritten rules were established long ago, prior to 21st century advances in science, technology, and medical practice. Many of them are now outdated – obstructing clinical excellence and holding our nation back. He believes this accounts for statistics that show Americans receive the most expensive and least effective care in the developed world. (He doesn’t give the source of this information.)
To address this problem, Dr. Pearl suggests we break the rules of healthcare, beginning with Rule #1: The best doctors are the ones with exceptional memory.
It is true that without an exceptional memory and the ability to regurgitate enormous quantities of facts, no student striving to become a physician will succeed. The system of pre-med college courses and the medical school curriculum demand this of all doctors. Dr. Pearl says roughly 50,000 graduating college seniors apply for 20,000 medical-school openings each year. The most important determinant of success is their scores on the MCAT or STEP exams. If you’re below the 80th percentile, you probably will fail.
The reasons for reliance on these tests are their shown ability to identify the best minds at retaining information. However, in today’s world of hand-held smartphones, a wealth of information is available literally at our fingertips. It only takes a moment to look up the facts that previously you needed to memorize.
Therefore, Pearl says to find the ideal doctors for the 21st century, a better rule would be to identify candidates who can:
(a) use modern technology to access reliable information
(b) synthesize medical data into a coherent treatment plan
(c) effectively communicate that information to patients from diverse backgrounds.
He says physicians who do these three things, consistently, can deliver far better care than doctors of the 20thcentury ever could.
To make this transition and help medical schools and residencies identify and train the ideal doctors of tomorrow, he suggests two initial steps:
- Modify standardized testing – Instead of the MCAT and STEP exams, which are day-long marathons of applied memorization, he suggests a more useful exam would require participants to employ 21st-century tools to solve 21st century medical problems, the kinds of complex challenges doctors encounter in real life. He would allow mobile technology during the exam to test their ability to use it to solve problems.
- Change the curriculum – Change the STEP exam to a PASS/FAIL to diminish the emphasis on memorization and cramming for the exam. He thinks second-year medical students are spending too much time in preparation for the exam and not enough doing classwork.
Dr. Pearl says, “Breaking the outdated rule for selecting medical students and residents is only a first step toward transforming American healthcare. There are many more rules left to break.” His series will cover four more rules he recommends breaking. We will discuss those in the future.
Healthcare is certainly changing. I wrote a book about it called Changing Healthcare! I vividly remember the first day of medical school when the Dean told us, “Half of what we teach you in the next four years is wrong. We just don’t know which half that is. Therefore, the practice of medicine is a life-long commitment to education.”
For now, I am somewhat skeptical of Dr. Pearl’s suggested changes, as you might expect someone to be who was trained in the “old school.” There is no getting around the need for every medical student to inculcate large volumes of information in order to effectively function as a physician. While modern technology does avail us of instant access to a wide variety of information, the time needed to find that information is often unavailable in clinical situations. When a patient’s life is on the line, I hope my doctor won’t be burying his nose in his cell phone, grasping for answers.
