An Innovator in Medical Education

"Knowledge acquisition is all about discipline," says a character at his entrance interview for medical school in Dr. Vincent Lam's award-winning collection of stories Bloodletting & Miraculous Cures. The surprised interviewer asks when academics had turned into "knowledge acquisition," an activity like "buying a house, or a hostile corporate takeover."

The notion of cramming all the knowledge possible, regurgitating it at exam time, and then miraculously holding onto that information throughout one's medical career has become "old school" in medical education. Instead, schools today attempt to produce doctors who are learned, but also equipped with the skills and attitudes of lifelong learning and critical thinking. There is a need for doctors who are fully engaged and versatile, almost like modern Leonardo da Vincis.

The Revolutionary

Hamilton, Ontario-based McMaster University has been a world leader in innovating medical education. The "Mac" (as it is fondly called) revolution starts right from the time of entrance applications. While medical schools now accept people with so-called flaky arts backgrounds, McMaster has gone one step further and abolished the MCAT, the science-based entrance exams required by most schools. Instead, McMaster hopefuls submit detailed written packages, including a reflective autobiographical essay, and go through MMIs (multiple mini interviews) in order to gain entrance to the program.

The Revolution

McMaster's curriculum substitutes the traditional, large hall and lecture format in favor of small tutorial groups led by MD tutors. Real clinical cases are used in class. There are no assigned readings. The assumption is that medical students are mature, keen to learn, and will take responsibility for their own reading and research. McMaster's website strikingly declares that "self-directed" does not equate to "self-indulgent." Mac students are encouraged to develop analytical skills and the ability to decipher and synthesize important information. The emphasis, at all times, is on developing medical knowledge for life, not for the next exam. Even testing at McMaster is different, designed less to quantify and achieve dazzling grades, and more as a tool for students to track their educational progress. Of course, once they complete med school, McMaster grads still have to take the Medical Council of Canada (LLMC) exam in order to obtain a license to practice.

The Results

While McMaster's program has been on the leading edge of medical education (Harvard University in the United States has modeled its program on McMaster's) and problem-based learning (PBL), pioneered at Mac, has been expanded beyond the health sciences, the methodology is not above criticism. McMaster grads have been teased for being "hippy doctors" who didn't know their anatomy. However, first-year student, Kate Reeves, responds, "Mac grads are at the top of the heap in getting their choice for residency programs." Veronica McGuire, a community liaison in the McMaster health science faculty, confirms this, adding, "In the 2006 Canadian Resident Matching Service (CaRMS) match, 69.2% of Mac grads received their first choice (for residency) compared to 63.7% of all other Canadian graduates." Despite letting students guide their own education, McGuire proudly says, "On average, Mac MD students meet or generally exceed the national average on the licensing exam."

Within the Ranks

Asked to comment on the experience of being a student at McMaster, Ryan Hoskins, from the class of 2007 says, "One of the greatest aspects of self-directed and problem-based learning is that it really allows each student to contour their education to what interests them … making learning exciting, high impact and relevant." At Mac, students can start electives after day one. Hoskins says, "The best way to learn is by doing and Mac really allows that." Another striking factor he points out is that without quantitative tests, there is an incentive for those in the program to help out everyone else.

When Hoskins (who has studied Latin American History and Economics and also has a Master's in Public Administration – credentials not uncommon in the program) is asked whether medical school was what he thought it would be, he replies that he had "a misconception that one should and could learn everything about medicine. In fact, the learning is endless, and some of the most powerful tools that can be acquired are when to know the limits of your knowledge, where more information can be found, and which disciplines and allied health could be referred to result in optimal patient care."

Hoskins also identifies the diversity of the student population as a great asset. He believes that it promotes an openness to people and ideas and a maturity that might not be found without diversity. Additionally, he thinks problem-solving and critical thinking are promoted by diversity. Mr. Hoskins comments that, "Rather than being shaped by medical school, students from different backgrounds are perhaps more willing to shape medicine. There will be a tendency to ask 'why?' more often. This applies to the big questions, such as asking why we should apply data showing lipid lowering medication is good for women when the research was done on men, to the most intimate of questions, such as questioning whether the abruptness of a physician to a patient was appropriate."

Hoskins is not above a critique of McMaster's program. He acknowledges that Mac produced legends such as the founders of MSF Canada and War Child Canada, but says that success and growth have unique costs attached. When asked to explain, Hoskins says that in Mac's early days, the class sizes were small – 50, versus 150 today – and students knew administrators and professors intimately. This allowed them to be confident in their different approach to medicine and also to know the philosophies and perspectives of classmates and teachers. Now, Hoskins believes, success and growth have led to a loss of intimacy and have lent a faceless quality to Mac, making this problem one of their future challenges.

Exciting Science

If Hoskins' capacity for even handed reflection and willingness to address issues both scientific and otherwise, is any indication of the new breed of doctors emerging from medical school, then the future of medicine looks very bright. Someone at McMaster appears to have heeded Albert Einstein when he said, "The problems of today cannot be solved by the same level of thinking that created them." Is it coincidence that a part of Einstein's brain is stored at McMaster's brain bank?

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