COLUMN: Code Red: Lectured to Death

From Bertie Bregman's "On Call," Fall '93 For the next few hours, you discuss what you've read and work on problems and cases. Sometimes the doctor presents a case to the group and asks for suggestions, elaborating on students' input and emphasizing key concepts. Sometimes the doctor lists problems on the board and has you pair up to solve them. The sound of animated discussion and debate fills the room. You are an odd number of students in the class, so the doctor pairs up with a different student each time, and has by now developed a personal relationship with each of you.... Suddenly an alarm goes off. At first you think of fire, but as your fellow students turn into blueberries which the doctor pops into her mouth, you realize that you are dreaming. You have overslept and your lecture on hypertension starts in 15 minutes. Your blood pressure begins to rise. You arrive at school and sit with a 150 of your fellow students in the lecture hall. The lecturer presents material from your course notes, and you follow passively along. If you reviewed the material beforehand, you are bored; if not, you are lost. Periodically, the lecturer strays from the text, and the room fills with the sound of rustling paper as everyone frantically tries to find the place. If you're Jewish, this evokes the endless days of prayer on Yom Kippur. As in synagogue, you do a quick calculation: it'll be over in 10 pages or 20 minutes – whichever comes first. You are momentarily hopeful – maybe you'll get to build a diorama about hypertension – but it turns into yet another lecture with a smaller audience. You leave school exhausted although you haven't actually done anything. You remember that you used to be such a happy child, and think to yourself, there must be a better way. If I were magically appointed dean of the Medical School, I would draft a constitution that read in part like this: We hold it self-evident that all learning should be dynamic and interactive; that lectures should be a tool of last resort, and that small groups and team projects should rule the day. Toward that end, we will limit class sections to a maximum of 10 students, and class time to a maximum of four hours a day. Students will be responsible for learning a body of material before class, and precious class time shall be used to solve problems and place the material in some relevant scientific and clinical context. We will make every effort to create a humane environment, conducive to an active life of the mind. Classes will be held around conference tables, with students facing one other instead of looking at the backs of heads. To develop into personal relationships with students, doctors will have ongoing relationships with groups. My constitution would go on, but at its heart would lie three sacred points: Seminars not lectures. Active learning. Mentoring. How crazy! How radical! And yet, how very much like so many other graduate school experiences! If Medical School administrators need a model to follow, they need look no further than the liberal arts. History or English graduate students come to class prepared to discuss the material. If you are reading Melville, you don't go to a huge lecture and listen to the professor read aloud from Moby Dick. You read the book at home and analyze it in class. You sit in a small group, around a table, and the professor moderates the general discussion. You come to class prepared because you don't want to look like an idiot, and the seminar dynamics make you an agent of your own education. If the liberal arts seem too foreign, then look at other medical schools, such as Harvard or the Medical College of Pensylvania, where students give rave reviews toEsmall group, case-study based learning. Or simply look at the literature, where studies show what common sense already knows: give students an active role in the process of their education, and they learn better and feel happier. Twelve percent of students develop a major depression during the first two years of medical school, more than twice the lifetime rate of the general population. Traditional wisdom attributes this to the stress of a heavy workload and the fear of failure, but really it has more to do with simple alienation. Alienation from our professors, whom we never get to know; alienation from the passive role of medical student, which requires the erasing of personality. But mostly, alienation from the curriculum, which is presented as an endless mountain of facts, whose nooks and crannies we are encouraged to note but not explore. Speaking for myself and for the minority of my class whom I know well, a slave mentality has set in. Resigned to our fate, we perform our tasks well enough to avoid the whip, but without joy or pride in accomplishment. We escape from the thought and reality of medical school at every opportunity. The more clever of us don't bother to attend class, and everyone devotes their energy and enthusiasm to other pursuits. I'm baffled by the 88 percent who don't get depressed. So what can we do, and who can we blame? Without ruling out a Masonic conspiracy, I think the problem is mainly structural. Thinking back on my college years, I realize that my outstanding classes were all seminars. Two of my seminar professors became close friends, and continue to inspire me professionally and personally. In contrast, the best of my lecturers I remember as you would actors in a play – characters painted in broad, but impersonal strokes. As a scientist would say, class size and structure was the best predictor of class quality; better than subject matter, better than reading list, even better than professor. We need administrators with the courage to overhaul the system, and create a school where inspiration replaces alienation. Medicine is intrinsically exciting, so why are our medical students so bored and depressed? Band-aid approaches like psychiatric counseling or evening seminars on top of a 30-hour weekly lecture load don't help. They're like putting architectural flourishes on a rickety old tenement. We need to start from the ground up, maybe with an alternative, parallel program, based on sound educational principles, that students can attend voluntarily. That way, comprehensive reform can be instituted incrementally, and without a huge capital outlay. I don't envy the dean who takes up the cause. Like Gorbachev, he or she will face conservative resistance at every turn, without even the consolation of a Nobel Peace Prize. But at the end of the day, we will have that dean to thank. Because the depressed, frustrated medical students that the system creates, are the cynical doctors that we all eventually get. Bertie Bregman is a second year Medical School student from New York, New York. On Call appears alternate Thursdays.