The weekend of November 4 was bustling in Boston. As the nippy winds of early winter settled into the northeastern city, energetic physicians and medical trainees hustled back and forth down Newbury Street for the annual conference of the Association of American Medical Colleges. This year, over 4,500 people attended the annual Learn, Serve, Lead conference, whose focus is on innovations and future directions in medical education.
The conference began with a keynote speech by David Brooks, author of The Road to Character and famous New York Times columnist. He began his speech with a hopeful assertion: “I know there’s a community that doesn’t just want to train technically proficient doctors, but wants to train full human beings.” Amidst a room full of scientists and evidence-based fanatics, the writer continued with another powerful and startlingly distinctive introduction: “I’m going to talk about education in the broadest sense, as something that happens to the head, heart, body, and soul.”
Educational innovation and curriculum changes have recently become hot topics in the medical world. Traditionally, the medical school curriculum started with two years of intensive lecture-based didactics, followed by another two years of intensive clinical rotations, with seemingly innumerable institutional and national tests and evaluations interspersed throughout the four years. The experience culminates with residency applications, which demand that students have not only excelled academically, but also found time for personal networking and research productivity. All this, while the majority of students are in their mid-20s to early-30s, pivotal years for personal growth and identity formation.
It is no wonder that the record-breaking rates of medical student depression and suicide were perhaps the leading problems discussed at the AAMC conference. Worse yet, these statistics do not abate once medical professionals have completed their education and embarked on the beginnings of what most ironically envisioned as a remarkably fulfilling and passion-filled career when they first submitted an application to medical school.
Thick Versus Thin Institutions
Brooks went on to speak about the difference between what he calls “thick” and “thin” institutions. “A thick institution is the one that is trying to leave a mark and does leave a mark. A thick institution seeks to change the person’s whole identity….it changes who you are forever after.” He identified efficiency as one aspect that “thins” an institution, saying: “Efficiency is great. It helps you build up hours. It helps you get more done. But efficiency thins organizations. Anything that is going to move your heart and your soul is thick and difficult. Efficiency allows you to pass through and get a lot done without actually changing who you are.” Brooks teaches at Yale University, where he meets numerous strong students who go on to train at prestigious medical institutions and acquire impressive accolades. However, during his time at Yale he has noticed that many of these students are unable to handle the personal challenges posed naturally by adulthood once they arrive at their mid-20s, due to a lack of prior identity formation.
Yet if there were a simple solution, surely the highly intelligent group of American physicians would have found it. Brooks’ speech was followed by a starkly different one by Marsha D. Rappley, the previous chair of the AAMC Board of Directors and Vice President for Health Sciences at the Virginia Commonwealth University and CEO of the VCU Health System. Comparing the equally powerful messages behind these two speeches lends us insight into why the challenges of perfecting the U.S. medical education system have not yet been solved.
The Cost of Medical Education
Rappley spoke about the prohibitive cost of a medical education. She discussed new ideas to improve the efficiency and thus indirectly decrease the costs of medical education, including the concept of condensing the traditional four-year curriculum into three years. She spoke pragmatically, urging medical leaders to turn their attention to the financial debacles both the U.S. healthcare and medical training systems have become. While allowing the time for identity formation and personal growth is an essential component of a healthy medical training environment, an equally anxiety-provoking reality is the long-term financial burden a drawn-out education costs. Thus, medical education has yet to strike a balance between adequately addressing this challenge and retaining the “thick” institutions Brooks advocates for.
As a medical student, I realize how reflective both of these sides are of the reality of our medical education system. Though I wish I could suggest a solution, I have yet to devise a satisfying compromise. The best I can do is emphasize the importance of mentorship. Fostering strong, supportive relationships with mentors has proven the best way of finding guidance in my career and identify formation, and retaining the sense of a “thick” institutional foundation in the midst of the an ever-quickening, rigorous medical school curriculum.
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