The Art of the Possible
Peter L Schwartz, Christopher J Heath and Anthony G Egan
Otago University Press, $39.95,
If the decision to review a book in New Zealand Books were made on the basis of how many readers are thought to be the target audience of the book, then this review should end here. This book is targeted at medical educators in traditional medical schools who are attempting curriculum revision. It is a description of the process that has taken place at Otago University Medical School. I am sure that most of the detail in the book is well known to the medical educators from Otago. Auckland is too young to be considered a “traditional” medical school. So arguably there is no New Zealand target audience.
Fortunately this is an important book for other reasons. It gives a well written detailed account of what is taught in a medical degree. The recent controversy over the teaching of “cultural safety” in nursing training shows that there is considerable public interest in the content of training for health professionals.
It is also a clearly presented description of an attempt at significant institutional change using the “evolutionary” rather than the “revolutionary” method. This book is about the process of trying to introduce “problem‑based, self-directed learning” to replace the traditional methods of teaching.
Traditionally medicine has been taught as a series of disciplines. After completing a basic science intermediate year the student learns anatomy from specialist anatomists, physiology from specialist psychologists, biochemistry, behavioural science, pathology, etc etc. The presumption is that you learn all your anatomy in the first year and remember it for the rest of your life; likewise for all the other subjects. This could accurately be described as a linear model. Whilst there is no doubting the knowledge of the departmental teachers, there is significant doubt of their ability to determine what degree of detail a future doctor needs in their disciplines. With the burgeoning of medical knowledge, the amount of information in each discipline is enormous and whilst this manner of teaching might have been OK 50 years ago, it is impossible now. The end result is that students are presented with a huge mass of knowledge, much of which is out of date by the time they have been in practice for 10 years.
More than 20 years ago this approach was challenged by some new medical schools. The best known are McMaster in Hamilton Ontario and Newcastle New South Wales. They have based their medical training on a problem‑based, self-directed learning model. In this model right from the start of the course students are presented with clinical problems and with the help of staff are guided in learning the information they need to know to understand and treat these problems. The same problem may be addressed several times during the course, each time looking into the problem in more detail and building on the knowledge gained through the course. This could be described as a spiral model with the student frequently passing the same point on a circle but at a higher level.
Reading the detail in this book about the old curriculum and the proposed problem‑based curriculum is an excellent way to understand the important differences between these two modes of training. In the former all the teachers are highly specialised in very small areas of knowledge; in the latter the teachers still have that specialised knowledge but show how to use it to solve problems and where to go to get the knowledge which they do not have. The former method of teaching is an important source of the frequently heard criticism of doctors that they are not “holistic”. The latter makes the whole training process focused on patient problems and inevitably engenders a more holistic approach.
I believe the public at large does have strong views about what it expects of doctors. I believe that the public at large would strongly support problem‑based self‑directed learning in favour of the traditional methods. The book points out that an important reason why they have not yet achieved the degree of change they would like is because there has been little external pressure for change. This book is an excellent place for lay people to be informed about these issues and to perhaps create some of that external pressure.
Much institutional change in New Zealand in recent years has been done by “revolution”; bring in a new chief executive officer and “restructure” without attempting to gain the support of the people in the organisation. There is no doubt this method has achieved results in many areas but there have been significant costs. The “evolutionary” approach to change is less damaging to staff, is arguably more likely to get the answer right but is at a severe risk of failing to achieve significant change.
From this perspective the book is about dedicated professional educators trying to achieve change from within a very traditional institution. The detail presented is the maximum that a non‑specialist reader could tolerate and the minimum required for the more specialist reader to document the political process during this time of change. The material is clearly laid out with a summary at the end of each chapter highlighting successes and failures and what lessons could be learned from these. The book places these attempts squarely in the international context, frequently referring to experience at other medical schools and with many detailed references. Whilst it is a story about change within a medical school, the successes, failures and lessons learned could apply to attempts at changing any traditional institution. On balance I think they have documented an example where evolutionary change was the better course.
20 years ago when I was doing my training Peter Schwartz stuck out from the other lecturers as being someone committed (some would say obsessively so) to medical education. I still remember the rather disconcerting experience of my first lecture in clinical biochemistry when it became clear that the lecturer was able to address every student in the class (all 200 of them) by name. Each year he memorised names and faces from the class photographs before meeting the students. Peter Schwartz “[i]n the interests of consistency in the style of writing … wrote the first drafts of most of the book”. His skill as an educator stands out in that he has managed to make a story about change in a highly specialised field readable to a reader with a limited interest in that field.
I have no doubt that there will be those within the medical school whose feathers have been ruffled by this process of change and who will suffer further ruffling on reading this book; but throughout care has been taken to avoid personalising any issues (all references to individuals are by title of their position not by name) and presenting the arguments in a logical and scientific manner.
The title is particularly apt. I am sure it is intended to refer to the changes in the curriculum they have achieved and that the art refers to using judgment as to how to work out what change is possible. However it would be a superb description of what medical education should be. As it was taught when I was a student, the task we were presented with was impossible. We were expected to memorise vast amounts of facts and were put down by our teachers if we did not memorise what they thought we needed. There was an over emphasis on science and little recognition of the art. I can’t help but think that this method of teaching combined with a perfectionist character might have something to do with the number of young doctors I know who have committed suicide.
Medical education based on students finding out for themselves as much as they need to deal with a problem and learning how to learn both is possible and encourages the important art of deciding what information is needed to solve a particular problem. Studies on students taught in this way show that their grasp of the “facts” is, if anything, better than students taught traditionally. I have no doubt there is a much better chance of students taught this way retaining a holistic view of problems and appreciating the art of medicine.
This book is well written, an important book in its specialist field with significant general interest. If you have read this far I have clearly convinced you that this book did deserve reviewing.
Ben Gray is a general practitioner in Newtown, Wellington, who attended Otago Medical School 1974‑1980.