Attendance among medical students reaches a low point: How will they become “attending” physicians?
Myron Yaster MD, Justin L. Lockman MD MSEd, Alan Jay Schwartz MD MSEd
I found this article from NPR Health (1) in my inbox the other morning and all I could think of was “Whoa!”
It turns out that medical students pretty much no longer attend “live” lectures. Instead, they opt to watch the recordings of their lectures at home at their own time and schedules. And often at 1.5x speed to save time. My good friend Dr. Alan Klein told me about this even before COVID and, to be honest, I was shocked… and this article confirmed his view. The COVID pandemic only accelerated the trend. How will this shift in medical education affect future doctors? How should or will it affect the cost of medical education? How should our ongoing continuing medical education (think: SPA and ASA meetings) change to reach future colleagues who are growing up in this new reality? I’ve asked Drs. Justin Lockman and Alan Jay Schwartz, who have MSEd degrees and constantly think about these issues, to chime in and assist.
And please take a moment to remember those who fought and died on June 6, 1944…D-DAY Myron Yaster MD
The only constant [in medicine] is change – and medical education is no exception. A colleague once told me [JLL] that the best thing about giving exams to medical students is being able to recycle the same multiple-choice questions/answers – with the “best answer” changing from year to year!
In fact, medical education may change rapidly in content but is slower than most other fields in format. Consider what the past 20 years has brought: online learning management systems (your hospital probably uses one for “mandatory education”), YouTube, and Massive Open Online Courses or MOOCs (e.g., “Coursera”) for starters. Not to mention the flipped classroom, interactive and relevant education (case-based learning, workshops, etc), and wide acceptance of TED talks and similar brief, focused messages (including at SPA meetings). And yet, our students are still expected to sit in a classroom for hours each day and listen attentively. And a majority of faculty teaching those lectures haven’t even considered changing their teaching style – after all, it worked in 1850 and 1950, so why shouldn’t it work in 2023? [As an aside, we think it DIDN’T work that well in 1950!]
Should we be surprised by students who are savvy enough to recognize the failure of this system and no longer wish to attend live lectures, opting instead for virtual online training? Are we worried about the future of medical training with these “no-show” students? No! and No!
Will they be prepared and adequately trained to practice medicine? Our answer is a resounding, YES, they will be adequately (and perhaps better) trained to practice medicine than when we sat in the lecture halls years ago.
Unwilling to speculate as we have, Everitt, Johnson, and Burr (2) completed a qualitative study of medical students to determine their motivations. They based their interview queries on a comparison of current medical student perspectives with prior student opinions catalogued during a famous 1960s study of medical student culture at the University of Kansas School of Medicine. (3) They described 2020s medical student learning strategies in the following manner (with some editing/editorial by AJS and JLL to link this to Anesthesiology Residents and Fellows):
1. Medical students, both in the 1960s and now, want to study the voluminous content in a most effective and efficient manner. We don’t have certainty about how to achieve this – it’s likely not “lecture” – at normal or even high-speed viewing.
2. Success at high-stakes exams is major driver of medical student studying behavior. The medical student view is riveted to “playing the game.” The long-term process of “checking off the required boxes” enables them to get into medical school and eventually reach their desired specialty. Students describe USMLE Step 1 scores as capable of either facilitating or forestalling a medical student’s entire career. Is success with the Anesthesiology Board Certification process analogous to the USMLE Part 1 goal?
3. Digital media has emerged as an effective way to assist/supplement medical students in studying for the USMLE Part 1 exam. In analogous manner, there is a plethora of digital media resources from which Anesthesiology Residents and fellows can learn.
4. Students believe that relying on third-party online exam prep resources is a high-yield learning strategy.
5. Students know that digital recordings of their medical school classes are available.
6. Medical schools reinforce the importance of high-stakes exams by focusing on outstanding performance on USMLE Part 1 to sustain institutional status among peer schools and to recruit top incoming students. Anesthesiology Training Programs focus on outstanding performance on Certification exams to sustain their program’s status among peer programs and to recruit top incoming residents and fellows. But does passing any of these exams represent “good doctoring”?
7. Students come to view class attendance as a waste of valuable [and limited] time. That does not mean that they view the content of their courses as worthless. They believe they can just learn it more efficiently and effectively through digital recordings. Students work hard to cover their course material in addition to studying third-party digital resources.
8. Students question the effectiveness of some teachers. Students recognize that some clinical professors are so busy that, when lecturing, they simply read off their slides – which may not have been viewed since last year’s lecture.
9. While many medical schools have not mandated lecture attendance, small group seminar attendance is commonly mandated in order to support a curriculum that is enriched with patient interviewing skill development and consideration of the psychosocial aspects of patient care.
This understanding of medical student learning preferences and some of their parallels in anesthesiology education provides a rational context for students not attending lectures. It also acknowledges that students do learn – and perhaps provides clues about how they effectively and efficiently accomplish this education and how we might better support them in the process. The implication to advocate for innovative teaching techniques may be obvious, but we’ll say it clearly: Students don’t come to lectures because lectures are not as valuable for them as we (the lecturers) think they are. It is our responsibility to do better, and to engage their brains, not just their ears!
The NPR Health article, which is concise and well worth your time to read, argues for the need to “flip the classroom” during the first 2 years of medical school. “In this model, the in-person lecture all but disappears, and students learn most of the classroom-type material on their own before in-person time — hence the flip. We suggest starting with a series of virtual modules to prepare for case-based small group sessions held in person. Activities such as anatomy lab, patient interviewing and physical exam practice and special guest lectures would remain in-person. This, in essence, embraces the virtual lecture trajectory but requires actual attendance for small group hands-on learning.”(2)
We agree: flipped classrooms, as well as case-based learning, interactive small group learning sessions, simulation-based medical education, and other hands-on educational activities/workshops for residents/fellows will help facilitate the ability to learn complex anesthesiology content and ultimately to succeed at both safe/effective patient care and “long term” career success in the form of fellowship and professional positions. One caveat: engagement requires participation both ways. The flipped classroom will always fail if trainees don’t come prepared/having read the assigned materials – and we have encountered this in our own practices.
Obviously, this trend and new reality has important implications. Will student-teacher and student-student relationships suffer? Will this decrease the cost of providing “live” medical education and will this reduce the cost to the student of attending medical school? Will there be a future medical school (MOOC) for thousands? We suspect the answer to all of these questions is “No.” Medical school has been interactive and individualized on some level for over a century, and that’s the really expensive (in time and money) part.
Perhaps equally importantly: How will this affect medical school faculty? Will virtual classes “remove the gratification that comes with face-to-face teaching and are we at risk of losing the commitment of faculty, much of which is often done on an entirely voluntary basis?”(1) We certainly worry about this, but personally we have found that engaging education is far more gratifying than lecturing at a podium.
Another major consideration for leaders is about how to maintain a learning/inquisitive culture in departments where, increasingly, trainees and faculty alike prioritize everything except for attending live educational sessions.
What are your thoughts? Please send to Myron who will post on the Friday Reader Response.
References
1. Philips AR, Gruppuso P. Medical students aren't showing up to class. What does that mean for future docs?: NPR, 06/01/2023.
2. Journal of Health and Social Behavior 1–16 American Sociological Association 2022 DOI: 10.1177/00221465221118584.
3. Becker, HS, Geer B, Hughes EC, Strauss AC. 1961. Boys in White: Student Culture in Medical School. Chicago, IL: University of Chicago Press.