Are Med Students Unprepared? Who's to Blame?

Schools Need to Invest More in Faculty

Robert M. Centor, MD


March 23, 2018

We learn how to act as physicians through observation and experience. This is particularly true during medical school, where attending physicians and residents shape interns and students through their actions. Unfortunately, we have many medical school leaders and clinician-educators who know how to talk the talk, but are deficient at walking the walk.

Recently, the American College of Physicians published a position paper that contrasts the hidden curriculum of lessons students learn from faculty who act at a lower standard than the standard described in the formal lectures they hear on ethics and professional behavior. Lectures rarely change behavior; witnessed behavior often does.

But although we can state that we need more outstanding role models, making that happen proves more difficult than simply saying so.

How can we break the cycle of unprofessional behavior? What should we expect from our clinician-educators? Why are they not always outstanding role models?

In most medical schools, clinician-educators receive less financial and emotional support than they deserve. Many medical schools seemingly value funded researchers as their greatest asset, followed by highly specialized subspecialists who bring in high-revenue patients. Too often, teaching occupies the lowest rung in the prestige ladder of medical schools.

Many clinician-educators carry heavy clinical loads. In medical schools, as in private practice, heavy clinical loads can create burnout. So, many clinician-educators suffer from burnout. We all know that burnout affects our personality and our professionalism. Some such physicians have the inner strength to maintain their professionalism, but unfortunately, not all do.

We also do not evaluate clinician-educators as completely during the hiring process. A researcher's scholarly activity is heavily scrutinized, and the recruitment team tries to estimate whether he or she will receive funding and have a highly successful career. Highly subspecialized experts generally come from fellowships with a documented ability to provide tertiary or even quaternary care. But too often, we recruit clinician-educators to fill a hole in the schedule. Few starting clinician-educators have taken education courses or even read books or articles about clinical teaching. Rarely do the recruiters even review their educational track records.

So some new clinician-educators, often fresh out of residency or fellowship, do not understand their roles and fail the role model test; some, of course, are great. Regrettably, schools often catch only the most egregious unprofessional behavior.

We do not reward positive role models. At many institutions, only one of the many clinician-educators will receive an award for professionalism. Few schools have a mechanism (or perhaps even desire) for recognizing and rewarding those who work with medical students, interns, residents, and fellows and provide important successful role modeling.

Too often, we recruit excellent clinician-educators and then overload them with clinical, education, and even committee activities. They often make much less money than their peers in private practice. Over the years, these great teachers and role models get frustrated with the medical school's apparent indifference to their contributions, and make the leap to private practice.

We relegate unsuccessful researchers to clinical teaching. These well-meaning physicians do not really want to teach clinical medicine. When this happens, it frustrates both these scientists and those clinicians who actively choose to be educators.

We owe our students, interns, residents, and fellows a first-class education. That education should include great role modeling. The best role models are skilled bedside clinicians, excellent at interacting with other physicians and healthcare workers.

But we should not expect great clinician-educators to reach that level magically.

Some organizations have invested resources in programs to help clinician-educators improve. The American College of Physicians has a wonderful book series titled Teaching Medicine. The Society for General Internal Medicine (SGIM) has developed a very successful program, The SGIM TEACH Program: A Curriculum for Teachers of Clinical Medicine. Other medical organizations also have on-site training programs on teaching.

Although these efforts are wonderful and include an emphasis on role modeling, compared with the number of clinician-educators spread across the country, we have insufficient resources. Right now, we inadequately prepare most educators before sending them out to teach our learners. Most students will tell you that some of them "luck into" outstanding teachers, whereas others have suboptimal experiences.

The ACP position paper addresses an extremely important problem. We all must work to convince medical schools that they should prioritize education and role modeling. Too often, education is almost an afterthought. Many great educators feel undervalued. Our students deserve better.


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