Having taught medical students for 25 years, practiced in several different medical fields, edited all the Medmaster titles in the basic and clinical sciences, and received feedback from many instructors and students through the years, here is how I would revamp the medical curriculum:
1. I would continue learning the basic sciences in the first two years, followed by 2 years of clinical experience, as opposed to the idea of learning the basic sciences and seeing patients right from the start. While one may want to see patients as soon as possible, it is better to first learn the basics, since you can then approach medicine with overall understanding, rather than scattered facts. It is like the juggler, who needs to combine a number of different skills to perform, such as simultaneously juggling 6 balls, twirling 3 hoops around one foot, and balancing a stick on his head. He would do better by first learning each skill separately and then putting them together, rather than trying to learn by practicing all of them together from the start. The basic sciences, though, should not be taught without reference to clinical medicine; they should be taught with a clinical emphasis, showing the clinical relevance of each subject as it is taught.
2. While small group discussions of clinical cases in the first two years can be an excellent source of learning for a given case, they tend to be an inefficient way to learn. They are time-consuming and cannot get into the vast amount of medicine that has to be learned. Also, when scheduled in the basic science years, they are presented too early for an adequate understanding of the topics, since the student has not yet learned the underlying basic science. While case discussions in the basic science years provide a way to introduce clinicians into the discussion (as most basic science courses are taught by PhDs, rather than clinicians), clinical relevance can be introduced more efficiently through well-designed reading, audio, and video presentations.
3. There is an overload of information in the medical curriculum today. We need to focus on general principles and understanding as opposed to numerous esoteric facts. People are much better at understanding than rote memorization, while computers excel at memorizing detail. The game-changer in today’s education is that it is easy to search for facts as needed on electronic media such as the Internet, in contrast to the past, where one had to rely on the latest reference texts and printed journals or go to the library to search through tomes of Index Medicus for relevant articles.
By the end of medical school we forget many of the facts that we learned. And we do not acquire an overall understanding of many topics because of the deluge of information that we are hit with over the four years; we do not see the forest through the trees. It is better to acquire overall understanding and know where to search for further detail. Learning general principles with understanding is in itself a fulltime job.
4. I would, for the most part, eliminate classroom lectures. Lecturers vary in quality, and even when there is an excellent lecturer, it can be difficult keeping up with note taking and grasping what is being said in a fast-talking delivery, especially when tired after staying up late. Why sit through a classroom lecture when one can learn the same thing through a YouTube or other video venue, at one’s own time and pace, and stop and go back to review points for clarification? I think the best use of the future instructor will not be to deliver a lecture in a classroom, but as a facilitator in pointing to the best educational sources for the student and responding to student questions. Where an instructor has something special to relay to the student that cannot be found elsewhere, it often would be better to present it as a personal reference video than as a classroom lecture. The instructor should, however, be available for individual questions from students, whether in person or by electronic communication. This will not only be better educationally for the student, but for the basic science instructor, who in many cases would prefer to spend more time in research activities. Rather than repeating the same lecture many times, the instructor can point to a well-designed video that can be accessed by different classes.
5. There should be a detailed list that the student receives on entering medical school as to what material in the basic sciences to learn, with recommendations as to where to find the information. The student should largely learn independently. There should be periodic tests to insure that studying is not crammed in toward the end, when the tests are given.
The same should apply in the clinical years. The student should have a list of the most important clinical conditions, with suggestions as to the most reliable learning resources to diagnose and treat them, whether they are books, apps, or videos. As is, education in the clinical years is often not organized, with the student left on his/her own to determine what is important to learn. As in the basic sciences, there should be periodic tests of knowledge. Learning through direct patient care is also very important, perhaps the most important way of all to learn. After seeing patients in the hospital each day, the student should seek out information as to differential diagnosis and treatment of the conditions seen that day. The student cannot learn everything, but by focusing mainly on the illnesses of the day, at the end of the four years the student will have studied the most common diseases.
6. Exams, including the Boards, should not present ‘gotcha’ questions, but basic information highly relevant to practice. So what if the questions are so basic that nearly everyone can succeed at the tests. They should be designed to confirm that the student has the necessary practical knowledge base. With the time saved by teaching general principles and promoting understanding in the basic sciences, rather than an overload of esoteria, the student will have more time to review for the Boards and study medical topics of personal interest.
7. While this may seem to be a “minimalist” approach to education, it is not. In the end it would maximize a student’s overall understanding of medicine, while inculcating a lifelong method of seeking out detailed information as needed.
What do you think?
MedMaster 
Much of this is how it used to be in times bygone. But since medicine has become so competitive, such as with the USMLE scores all but determining which specialty one matches into, the “gotcha” questions et cetera have now become the norm rather than the norm being the norm. Or so medical educators seem to think. Now med school is all about gotcha questions, one upmanship, gunners, pimping, and many, many, MANY other horrors in medical education. I pity med students today!
If even excellent, highly experience physicians have difficulty answering the gotcha questions, are we not emphasizing the wrong things? While learning a certain number of key facts is important, it is a shame that medical students often are reduced to rote memorization of isolated facts, when they, and their future patients, would benefit more from the acquisition of understanding of general principles related to patient care.
“The basic sciences, though, should not be taught without reference to clinical medicine; they should be taught with a clinical emphasis, showing the clinical relevance of each subject as it is taught.”
Wouldn’t it be better if students were introduced into clinical medicine so that they can by themselves discover “the clinical relevance” of each subject as it is taught?
My view: It is not that by introducing clinical medicine, the student is trying to learn multiple things together. It is for the above issue of the student being “able to know the clinical relevance” of each basic science material that is taught to him!
In my country, Jordan, we take three years of basic sciences. Now, I am at my final year. I wish that the basic sciences years return. The reason? Because they taught us EVERYTHING and I didn’t know what things to concentrate on because they will be clinically relevant!
Respectfully 🙂
Yes, seeing patients right away does give some idea of clinical relevance. However, there are many hundreds of points in the basic sciences that are clinically important and one is barely scratching the surface of learning them by starting off seeing patients. It is the job of the basic science instructor, when methodically going through the topics in the course, to simultaneously explain to the student the clinical relevance of what is being taught and to carefully select those points that are most important clinically. The problem is that many basic science instructors are not clinicians and do not have a clear idea of what is clinically relevant. So they try to teach as if everything might be clinically relevant someday. However, this is too much information to absorb; it is optimal to select that material that is most clinically relevant now, and to leave it to the student to fill in on more detail when they see patients in later years and more facts become clinically relevant. Yes, seeing patients from the start is helpful when the instructor does not teach from a clinically relevant point of view. But this way of learning is not optimal in my view. As I see it, it is better to first teach the basic sciences from a clinical perspective and afterwards reinforce this with patient care.
I would certainly support you if you put together a team to create something like this:
“There should be a detailed list that the student receives on entering medical school as to what material in the basic sciences to learn, with recommendations as to where to find the information.”
Dr. Goldberg, have you considered starting a medical school? It would be great for someone to start a medical program that does what you mentioned in the first two years, and for years three to four form partnerships with teaching hospitals, while providing the additional resources you mentioned. I also had a few ideas.
If professors were compensated primarily for their teaching material contributed, and things were streamlined so that they need not teach in class, perhaps we could reduce the gross cost of medical education (professors could not estimate so highly the hours they contribute, so that the school is not billed that percentage of their salary).
I also wonder if there would be a way for a school to integrate teaching using an already existing paid service like Pathoma, FireCracker (aka Gunner Training), FirstAID/USMLERx, and USMLEWorld (less than $1000/year total, in comparison to $30,000), which would holistically be very extensive in their teaching if we had all of our time to focus on these well organized resources rather than our classes. Anatomy lab could be charged for separately, along with school fees for small group sessions, Clinic/faculty mentor sessions, clinical skills, Harvey sessions, etc. Then we could all know what we are actually paying for.
Someone could even create a school like this as non-public, and non-“private”, as social entrepeneurship, feeding all proceeds from this already extremely affordable program into some other humanitarian related effort. Even if not, as a business, this could be fantastic. Of course an overhaul of existing public schools would be ideal, I just have little hope on seeing anything like this quickly adopted, or even if it is, they would probably leave the costs the same… or increase them because it’s simply a better method… though I truly hope not.
Perhaps this could even give more people the opportunity to become physicians since classroom size could be potentially increased, as long as the hurdle of managing adjunct faculty/activities and 3rd 4th year partnerships was overcome (granted much easier said than done). Small groups could even be conducted in Google Chat sessions with a Virtual whiteboard and Bamboo Tablet. Basically a model for more immersive but primarily online medical education.
I suppose the problem I have not thought about enough is that we already do not have enough residency programs. One of my end goals was lowering patient volume for clinicians, especially in primary care, and getting more physicians willing to work in rural areas. It just seems poor to me that many applicants to medical school are not accepted due to the limited spots, many of which I know have what it takes to succeed and become excellent physicians.
New schools seems to be opening up all over lately, maybe something like this could really happen. The more I write in this the more it makes me consider rallying for this throughout my career, or even trying to start something. Let me know your thoughts, and if you think any of this sounds feasible in the least, I love your work. Thank you!
Respectfully,
MS2
Thanks for your input, Eric. You present some great ideas. It would be an enormous undertaking starting a new medical school. It would seem best to try to work within the structure of an existing institution to effect change, although this can be difficult in itself. I like to think of Medmaster as already, through the years, trying to establish an optimal curriculum simply through the books it publishes, which try to sort out the clinical relevant material from that which is not, presenting the student the information that is most important to know as a clinician, in a way conducive to rapid learning.
While studying via Internet use to be too slow because of Internet speed, this is no longer an issue, and it would seem inevitable that much study in the future will take place on the Internet rather than in the classroom. You make a good point that enabling teaching online could increase the number of students who go through medical school, and lower patient volume for clinicians, particularly in primary care. With changes in the health care system, this could help alleviate the overload that physicians have in caring for many patients at once. It would also allow for a less expensive medical education.
Regarding Anatomy Lab, it is only a personal opinion (and I have taught in the Anatomy lab for 25 years), but I don’t think this adds greatly to a physician’s anatomical knowledge and surgical skills, and could well be eliminated in medical school. Dissection of the formaldehyde-preserved cadaver does not resemble the experience of operating on a live patient, and the anatomy might better be learned through the wide variety of print or electronic resources, with the real surgical skills being honed later in residency.
We are already seeing a proliferation of online courses and this likely will expand to include more creative ways of presenting education electronically in ways that you mention. I think that what you suggest sounds highly possible and noteworthy.
Idea of Clinical relevance to patients is required