Every year, thousands of bright-eyed teenagers start a 5 year journey to becoming doctors. In the beginning, their excitement is palpable: they want to learn as much as they can about the human body and mind, what can go wrong and how to save lives. But at some point, that excitement and desire to learn for it’s own sake is replaced by the pressures of passing exams and ‘getting through’ the course. Why is that, and what should we do about it?
Transforming Medical Education
‘Transforming medical education’ is far from a new idea. In fact, it’s probably up there with ‘patient centred’ and ‘paperless’ as one of healthcare’s favourite buzzwords.
But these phrases don’t come from a vacuum. Behind every overused buzzword is a reality they’re trying to describe. We talk about patient centred care so much because we recognise that it currently isn’t, and that a whole host of problems arise as a result.
So why do so many of us talk so often about transforming medical education, what does it mean, and what would a ‘transformed’ system look like? I think we all intuitively recognise that medical education could be much better than it currently is – whether through technological, pedagogical or organisational changes. Medicine is one of the most exciting and adrenaline-pumping careers one can aspire to – and every year that promise inspires thousands of the brightest and best individuals to apply and compete for a place at medical school. There are many answers to the dreaded interview question, “So why do you want to be a doctor?”, but in my experience a common theme is that people want to be a part of a career that is dynamic, acute and stimulating.
The A-ha! Moment
In Lean Startup circles, it is common to talk of the ‘a-ha!’ moment. The a-ha moment is when a user realises why they need your product. Identifying that point means you can focus your efforts to making sure as many users reach it as possible. Dropbox realised that once people have installed it on their computer and uploaded their first file, users are highly likely to stick around and continue using it, because they’ve experienced the value of Dropbox. Similarly, Facebook users hit their ‘a-ha!’ moment when people have added 10 friends, and Twitter when someone follows 30 people.
the difference between doing something because you have to, and doing something because you want to, is everything
Essentially, the a-ha moment is the point in time where an extrinsically-motivated user becomes intrinsically-motivated. And the difference between extrinsic and intrinsic motivation is everything. Extrinsic motivation means having to push and drag people through targets, and requires an inordinate amount of effort (usually marketing or onboarding initiatives) to do. Intrinsic motivation, on the other hand means that the user is doing something because they want to. They are internally motivated and aligned to the same goals that you are, and will not only meet but surpass expectations – your targets are now aligned with their targets. This distinction is the essence of all management theory, because we all know the difference between doing something because you have to, and doing something because you want to, is everything.
The ‘Screw It’ Moment
The natural corollary of this is what I’ve started calling the ‘screw it’ moment. The ‘screw it’ moment is when someone who is intrinsically motivated to complete a task suddenly loses that motivation, and either quits or subsequently has to be extrinsically dragged and pushed towards a goal they were previously excited about doing.
We go from being excited and intrinsically motivated to learn as much as we can about medicine, to being pushed through the course so that we can pass an exam
The ‘screw it’ moment is endemic in medical education, and represents a colossal squandering of human potential. Every year, thousands of young people become first year medical students, and arrive full of enthusiasm, motivation and excitement about starting a five year journey of learning about the human body, the myriad ways in which it can be compromised, and how to combat infection, cancer and trauma to restore health. Medical education, both as an undergraduate and in professional training, goes far beyond learning anatomy and biochemistry, and also encompasses psychology, behaviour, data analysis, technology and communication.
Having selected the best and most highly motivated people to train, medical educators should benefit from a huge advantage in the intrinsic motivation already present in it’s students. Unfortunately, almost every student hits the ‘screw it’ moment at some point in their training – whether in the first year or later on – at some point, there is a noticeable and irreversible shift in how we relate to our course. We go from being excited and intrinsically motivated to learn as much as we can about medicine, to being pushed through the course so that we can pass an exam. This key distinction was well-recognised in MacGregor’s ‘X & Y’ management theory (below).
If measured simply by the percentage of students who complete their course, medical education isn’t ‘failing’: the vast majority of students do make it through the course, and go on to pursue clinical careers. But shouldn’t we judge the quality of education against a higher standard than that? If medicine is taking a significant proportion of our top-achieving students every year, and puts them through one of the longest and most intensive undergraduate courses in the world, investing an estimated £250,000 per person – whether or not they pass the course is a phenomenally underwhelming expectation to set.
we’ll accept extrinsic spoon-feeding, especially if it helps us to pass exams, but in the process we lose our internal motivation
The problem lies in the ‘screw it’ moment. Targets, checkboxes and detailed instructions as to exactly what you should know, in what detail and what you need ‘to pass’ have their place, but in a population that is already intrinsically motivated, they should be used with extreme caution. When we are spoon-fed something, we eventually lose the will and the ability to do it ourselves. This happens biologically, for example people who take Selective Serotonin Reuptake Inhibitors for depression experience a rebound of symptoms when they stop taking them – the brain has become so used to being given Serotonin externally, that it ceases to produce it’s own. But it also happens psychologically – we all take the path of least resistance, so we’ll accept extrinsic spoon-feeding, especially if it helps us to pass exams, but in the process we lose our internal motivation.
The Future of Medical Education
The ‘screw it’ moment sinks in when we stop learning for it’s own sake, and start learning for exams. The endless list of ‘learning outcomes’, and the considerable time pressures involved in the medical degree means that even the best of us make a psychological switch from ‘learning to be a better doctor’ and ‘passing the exam’ at some point, and we sacrifice our intrinsic motivation in favour of extrinsic targets to achieve it.
When we talk of ‘transforming medical education’, what we should be talking about is not new methods of spoon-feeding students, or new learning outcome hoops for them to jump through. What we should be talking about is how we create an environment that capitalises upon, rather than extinguishes, students’ intrinsic motivation. In other words, how do we create a sandbox where medical students’ curiosity and interest is stimulated and facilitated, so that in 5 years they are not only competent practitioners, but eager and intrinsically motivated to continue learning?
I don’t know what the answer is, but it’s obvious that technology, along with new teaching paradigms and education models, will play a role in this – whether through innovative surgery simulators like TouchSurgery (below) that let medical students practice procedures in a virtual environment before practicing on real patients, or tools that allow for personalised, tailored learning such as my own platform Synap.
Freedom vs. Micromanagement
Technology is, however, a double-edged sword. Unfortunately, it is far easier and more intuitive for educators to use online learning as a way to introduce more extrinsic motivation and to monitor their students adherence to outcomes more closely. Designing a system that students use because they want to, is far more difficult, but infinitely more powerful. The fact that so many of the most popular online platforms are developed by medical students themselves – such as MediWikis, AlmostADoctor and TeachMeAnatomy – is a testament to what students can achieve when left to their own devices.
how do we create a sandbox where medical students’ curiosity and interest is stimulated and facilitated?
Indeed, giving motivated people the time to pursue their own interests is a driving philosophy behind many of today’s most successful technology companies. Google famously gives their engineers 20% of their paid time to work on something that interests them personally – and is where one of their most successful products, Gmail, came from. Innovation comes from the bottom, not from the top.
Of course, a degree of extrinsic motivation may always be necessary in the real world. I have about as much interest in geriatric dermatology as I do in the Mongolian shoe polish industry, but on the whole we should err on the side of freedom rather than top-down micromanagement of students’ learning, especially when we’re starting with some of the most enthusiastic and academically motivated people in the world.
Technology is opening up and enabling completely new models of education that would previously have been unfathomable. Medical educators should avoid the temptation to use that power to strengthen the existing top-down model of medical education, and instead use it to facilitate, nurture encourage students’ own natural curiosity. The benefits of this are already being realised with student created education platforms, but in a course structure that is truly conducive to ‘learning for learning’s sake’, who knows what Tomorrow’s Doctors could achieve?