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Medical Education
Bridges Curriculum

Shifting Ground: Bridges Curriculum Foundational Sciences Retreat, Part II

“So what’s the problem?” asked Professor of Neurology and Inquiry working group lead Dr. Dan Lowenstein. “We box ourselves in.” Bridges, he urged, provides a liberating opportunity: to teach any topic (he used epilepsy as an example) outside the compartments of time-limited blocks and disciplines. Spiral learning means that we can introduce, revisit, and reinforce concepts throughout the 4 years, and across different lenses.

The second opportunity, he proposed, is to break free of teaching “biodegradable factoids.” He held up his smart phone and asked, why should we focus so much on rote memorization when the information is instantly available. To that end, "Too much is focused on what we know, almost to the point of fictionalization." A more fully integrated curriculum, grounded in Inquiry as a habit of mind frees students to apply knowledge and empowers our faculty members to teach at the edge of the known.

How clinicians model inquiry matters. According to Dr. Robert Nussbaum, Professor of Medicine and Chief of Medical Genetics, an anti-intellectual strain infects our teaching language in the form of: “We see this.” This common aphorism signals the end to debate and investigation, just where it should start. Using genetics as an example, he urged us to prevent the basic sciences (as one form of inquiry) from completely “dropping off the cliff” upon entering the clinic. This is even more important in the context of the rise of direct-to-consumer genomic testing, where the interest of the public may outpace our clinical, legal, and ethical tools. A teaching culture that encourages continuous inquiry and the marrying of science to practice will chip away at these silos.

The feedback sessions reflected the potential growing pains ahead.  Some offered that students could "teach up" to their mentors, championing basic science on the wards. As a medical student noted, this will require faculty development to expect and encourage such engagement and side-by-side learning of faculty and students. Secondly, didactics might disrupt the flow of clerkships, or worse, not receive the buy-in and attention they deserve. The Bridges clerkship might look radically different from the past; changing what has been dubbed “the hidden curriculum” might prove hard to move. Supporting faculty and residents around new expectations and opening the clinic to basic, clinical, and systems sciences to cultivate a critically inquiring attitude might be the key.

Embracing Uncertainty

In the 1950s the preeminent medical sociologist Renee Fox established uncertainty as a central element in medical education. Learning to better manage uncertainty, she argued, was a core feature of transforming a neophyte into a professional physician. Others more cynically argued that managing uncertainty led physicians to assert control and professional dominance (Light, 1979). More recent scholarship has updated this work to go beyond a simple opposition between being uncertain and being in control. Rather, managing uncertainty—whether in the practice of medicine or in the evidence base—is a process that can result in either control or flexible accommodation (Timmermans & Angell, 2001). This process begins with medical students who, through honing the case presentation ("encasing the patient"), begin to learn to manage uncertainty (Holmes & Ponte, 2011). While uncertainty is a structural fact of contemporary medicine (at least from the mid-20th century on), it does not have to be a pretext for control or something to be anxiously coped with.

During her opening remarks, Dean Lucey conjured this daunting image of the certain and less-than-certain causes of breast cancer (Hiatt et al., 2014):

She said: "We want to create a generation of physicians who can understand this and embrace this." This complex chart references just some of the uncertainty inherent in medical care and etiology today. But complexity can mean either chaos or an opportunity. With an inquiring habit of mind that teaches to the horizons, embracing the unknown in the clinic, lab, community, or the wards, we can begin to turn uncertainty from something to merely manage to a challenge to openly and honestly embrace. 

 

References:

Hiatt, R. a, Porco, T. C., Liu, F., Balke, K., Balmain, A., Barlow, J., … Rehkopf, D. H. (2014). A Multilevel Model of Postmenopausal Breast Cancer Incidence. Cancer Epidemiology, Biomarkers & Prevention : A Publication of the American Association for Cancer Research, Cosponsored by the American Society of Preventive Oncology, 2078–2092.

Holmes, S. M., & Ponte, M. (2011). En-case-ing the patient: disciplining uncertainty in medical student patient presentations. Culture, Medicine and Psychiatry, 35(2), 163–82.

Light, D. (1979). Uncertainty and control in professional training. Journal of Health and Social Behavior, 20(4), 310–322.

Timmermans, S., & Angell, a. (2001). Evidence-based medicine, clinical uncertainty, and learning to doctor. Journal of Health and Social Behavior, 42(4), 342–59.