Department of Good Intentions, Office of Unintended Consequences

By Mike Moore

Going to a new medical school working its way through the accreditation process is, by design, a bit of an experiment. A school wants to establish itself as distinctive, but in the end, it seems that doing anything radical is out of the question. The drive to conform to professional standards and expectations is a good thing: It generally prevents schools from bilking students of grand amounts of money while leaving them unprepared for their respective board exams, and ensures that they are able to find placement in residency programs. However, there is an unexpected side.

The good intentions we have to protect students lead us to retain many parts of the old model, regardless of whether it is crucial to learning medicine or practicing it safely. In the end, out of fear of eliminating waste, coupled with a strong desire to add real value to the curriculum, schools give but rarely take away. The incredible explosion of biomedical knowledge over the past decade means that schools ask each successive class of students to absorb more knowledge. They ask us to accomplish more with less, and to do it in less time.

An excellent example is the addition of computer-based learning assignments to the clinical curriculum. Students on clinical rotations, especially in community-based clinical settings, usually attend 40 to 50 hours a week. Asynchronous learning assignments can take a significant amount of additional time. As other assignments are added, we can rapidly reach the point where the simulation, scenario, or case study takes the place of the patient contact—exactly the wrong direction that we want to go. We want the study to complement and strengthen the patient encounter, not reduce it to a case on the computer.

Unintended consequences come because we piecemeal a solution to a difficult problem without a strategy or understanding of how the entire process works. The only way to escape the tyranny of unintended consequences is to refocus the entire process on results: safe, effective physicians who are able to master the base biomedical knowledge and skills needed to train in a specialty. Perhaps the endpoint of undergraduate medical education needs to be different. But holding onto the past, adding more “stuff” to the old without changing the endpoint, is not a viable solution.

Our current course of incremental improvement in medical education does not seem to be adequate for the radical changes in health care that lie ahead for us. What will it take for us to “reset” our medical education system to better serve us all?

Mike in Library at end of Surgery Rotation - Feb 2012—Mike Moore is a fourth-year medical student at the Pacific Northwest University of Health Sciences College of Medicine. He can be reached at Follow him on Twitter @MichaelBMoore.

0 thoughts on “Department of Good Intentions, Office of Unintended Consequences

  1. “Results” (or from an educational research perspective, “outcomes”) are so hard to define in education that many senior (and even junior) faculty do not see the need to change. We only need to consider the empirical data that are seemingly obvious –that many Board Certified physicians are sub-par and fall below the radar for so long– to know in our hearts we need to change. Until outcomes of medical education are more well established this will be difficult to demonstrate. Outcomes-based education and educational research is coming. We are at a time that educational leadership has begun to recognize this, so we will absolutely see it.