If there is anything that requires critical thinking skills, it’s taking care of people who are ill. When someone is ill they have more than a disease. In fact, the clinician is presented with an individual whose homeostasis has been disrupted. Before you get sick, you have a routine and things are in some sort of balance: you go to school or work, find time to connect with friends and family, do chores, pay bills, take a shower, have sex, get rest etc…But when illness sets in, the precarious balance that is life before is perturbed. An effective clinician sees all this, and approaches the ill patient with a wide angle lens. He or she is able to discern what matters in a particular context. Our research on contextualizing care indicates that that ability is in short supply. A major culprit for such a profound competency deficit may be attributed substantially to a medical education process that still relies heavily on lecture.
First, a reminder, for those who have been out of school for a while….A colleague of mine with a lifetime of experience facilitating adult learning writes:
Lectures had been seen as the ultimate in efficiency – simultaneously force-feeding information into the ears of hundreds of students at a time as they were jammed into lecture halls with rows of fixed seating. Yet, in truth, the uncomfortable seats most often had too-small arms to support notebooks for the most inefficient mode of information transfer – from the mouth of the often mumbling professor, to the impaired ears of the students; set in a sea of noise from a hundred others scribbling, coughing, sneezing and shuffling impatiently; to the imperfect handwriting of a hundred ink-starved pens and broken-point pencils. This, for the past century and more, was the model of high-quality teaching (and learning). Forgetting the hearing-impaired, forgetting the sight impaired who could not read the black or white board, the lectures droned on.
Lecturing is basically telling people stuff while they are captive. It’s mostly unidirectional, and learners are rewarded for their regurgitating capacity. Once they’ve been through the system it becomes their turn to lecture to people. If they get PhDs they can lecture from a podium. If they get MDs they can lecture in the exam room. We hear doctors lecturing to patients about how they have to quit smoking, eat better, exercise more, take their pills…often using medical terminology, unaware that what they are saying is incomprehensible. What they don’t often do is ask their patient why they aren’t taking their pills or eating better etc…What does it say about a person’s critical thinking skills when they think they know how to fix something before they’ve looked into why it’s not working?
Lecturing at the lectern is equally illogical: The teacher is transmitting information without knowing the learning needs of a diverse audience. Some students, like patients, may benefit from the information transfer. But for most, there are other learning needs. I remember sitting in lectures in college on the French revolution and feeling like I walked in late even when I got there on time. I was lost from the beginning because I lacked a foundation of knowledge that the teacher assumed I had. Similarly, a clinician lectures a patient unaware of the underlying struggles that individual is facing. Most people who don’t take their medication as directed probably won’t benefit from a lecture on how important their medication is. What they need is someone who will ask them about their challenges integrating something new, scary and that often changes how they feel into their daily routines…and then help them find their own solutions.
Lecturing is disrespectful. Don’t get me wrong: some like it, which is just evidence of learned helplessness. Lecturing is based on the premise that I know what you need and I’ll do the talking. It is ego gratifying for the lecturer, as they have the attention of many others (or the appearance, thereof. Most are on Facebook). Most importantly, it puts the teacher and learner on an unequal plane. And that comes to model the relationship between doctor and patient.
Not all learning requires conversation. Rote memorization works best with flashcards. Comprehension comes from reading (lecture is an inefficient alternative with lower long term retention). But learning to solve complex problems — to analyze and evaluate information, and to formulate and test hypotheses (see Bloom Taxonomy) — that requires direct engagement with the material…and when the “material” is other people, it requires engagement with them.
As long as we continue to lecture medical students we are treating them the way we don’t want them to treat patients and we are denying them the opportunity to build the skills they need to provide effective care.