Are medical schools innovating excellence or inspiring mediocrity?

If there is one person in the world who understands why the great people in any field became great disputing the traditional sensuous talent myth, it’s Swedish Professor Dr. K. Anders Ericsson. Thanks to decades of researches lead by him on deliberate practice and human performance that it has never felt so convincing and certain to stand at one concrete side of “nature vs nurture” debate. In simple words, no matter how convincing your theory to blame your genes for not exceling in a particular activity is, the hard truth is that unless you are concerning about a field that is limited by your genetic makeup like height or weight your belief is definitely fallacious. Ironically enough, the very book Malcolm Gladwell “Outliers” in 2008 which popularized the ten thousand hour rule highlighting Ericsson’s researches from outside the scientific community, Ericsson after 8 years in his book “Peak” refuted the same with compelling and countless scientific evidences. Although medicine may not as objective as many other fields like chess, music or sports but since it is a highly developed field, the principles of deliberate practice can be very convincingly applied. You might have used various practice methods unknowingly from learning to speak, write, walk or learning to ride a bicycle or to cook a meal and so on. However for improving in any skill, field or domain the gold standard is deliberate practice and thankfully so it is not an all or none phenomenon. For literally anything in the world the effectiveness of all practice methods can be traced back to the degree that they resemble the principles of deliberate practice.

The classic pedagogy and probably the easiest and most convenient for both teachers and students is giving lectures. Easy for teachers as they can teach many students at once and easy for students as they don’t have to actively engage in learning activity. In other words unless the teacher starts asking questions or deigns an intervention to maintain the attention span, it’s a very cozy task to listen or pretend to listen to passive lectures. Here exactly the principles of deliberate practice are violated. The 20th century psychiatrist David Viscott was referring to this when he said “if you want to feel secure, do what you already know how to do. But if you want to grow. Go to the cutting edge of your competence, which means a temporary loss of security. So, whenever you don’t quite know what you are doing, know that you are growing.” Same hold true for The Learning Zone model developed by German adventure pedagogue Tom Senninger as when you are in the comfort zone. If you are in the panic zone, fear and all other negative emotions can hamper the learning process. The activity should be just outside your comfort level.

Other principles of deliberate practice like focus, specific goal and providing immediate feedback is very rare in lecture setting which leaves us with no wonder that though irresistibly convenient, speaking on efficiency it is one of the least effective learning strategy. Techniques such as demonstration, incorporating audio/visual aids or discussion can eliminate the shortcomings to an extent making it little bit closer to deliberate practice but the basic system of lecture doesn’t allow much room for improvement in most settings. Though passive methods of learning, techniques such as audio/visual aids and demonstration can be quite useful for learning in medical school compared to lone lectures particularly for introducing a skill to students like NG tube insertion or lumbar puncture or even teaching practical anatomy with cadavers.

Another method of learning in medical schools is Problem Based Learning (PBL). It consists of small number of students for group discussion. Audio/visual and demonstration can also be included but the primary focus is self-directed learning, group discussion and teaching others which are among the top rated strategies in the learning pyramid. Again from the deliberate practice point of view, one should engage in activities that are outside his/her comfort zone. If all you do is stay active in group discussion but without getting used to be uncomfortable, you would probably grow within small boundaries. Other great benefit of the system is unlike lectures the teacher or tutor is paying attention to each of the students and provide immediate feedback about the performance and whether the student is on course to achieve specific objectives of the session or not. Feedback which is the cornerstone of deliberate practice principles can also be generated from group discussion alone or while teaching others. Though it may not be possible to mould each student individually which would have been the deliberate practice in its strictest sense it still resemble the practice to a considerable extent. It’s possible that for an individual student, in a session of two hours the deliberate practice is of few minutes and that is a major advantage above other methods who have little or nothing to do with the principles of deliberate practice whatsoever.

Practical classes, lab works, demonstration and clinical skill classes are one of the most valuable of all teaching methodologies in medical school. Practical classes by definition should involve practical work in which each student must practice some skills he or she needs to learn. Unfortunately the irony is that in many classes all students are expected to do is merely watching and listening. This is very gloomy aspect as these are the methodologies that are outside comfort zone of student, they provide immediate feedback whether self-generated or by the instructor and teacher which helps students to modify their efforts corresponding to the feedback in order to achieve the set specific goals to improve particular aspect of student’s performance and many more. In short these are the exact same activities required to produce exceptional performance. Many factors might have accounted for the limitations including lack of enough resources, practical materials or clinical skill labs but again the fact to be kept in mind is the closer we can get to the ideal definition of deliberate practice the better the outcome would be.

Case based discussion (CBD), ward based teaching or seminars are effective but the effectiveness depends on many factors including of course the number of students in the group. If it is possible for the teacher to observe and provide feedback for improvement for each individual student based on his/her performance, then it would be great as it very closely resembles what is needed to create excellence. If not these teaching methodologies should target to be as close to the ideal as possible. For example in a group of 13 students teacher decides to teach physical examination skill in patient but first by examining the current knowledge level of the students. For that he chooses a student (obviously he can’t choose all for various reasons including patient discomfort and time factor). If he chooses a student which this skill is very difficult then he can provide feedback and improve on student performance. Contrary to that if he had chosen a student for which the skill is no big deal then it wouldn’t be of much effectiveness at least for the one performing the skill. These sort of small decisions though seemingly insignificant from guide, coach or teachers compounded over time have massive effect in a student’s life.

Clinical Presentations (CP) form the core of medical school curriculum in many instances especially in the clinical years. They are clearly superior to passive learning as they encourage active discussions, self-directed learning and enhance presentation as well as clinical reasoning skills among students. The teacher can provide immediate feedback while presentation which will both increase the academic learning and reasoning as well as sharpen the presentation skills. It also allows students to focus on creating presentations while actively learning and focusing intensely if he or she really desires to. Engaging in such purposeful and deliberate practice, which obviously is hard and intense modifies the structure of our brains changing specific neural circuitry, which fires action potentials when training a skill, get reinforced and gets increasingly complex. This serves to strengthen the ‘mental representations’ that will improve the skill or particular aspect of the skill of concern. One example of reinforcing such mental representations is while discussing a clinical case scenario in a class just pause and ask a particular student what he or she would proceed from then. From the response the quality of mental representations the student has in his/her mind is evident. It’s not possible to stop a doctor providing clinical care to stop and ask what he would do next in OPD clinic, it would otherwise seems absurd but such small action of responsibility in class can improve performance greatly at least for the individual student concerned without any dangers outside real clinical setting.

The concept of residential posting is also very valuable in medical school in which students are exposed to the ground reality outside the clinical setting. They can learn with supervision and in many cases get immediate feedback about many aspects including communication skills and modify the same as per the feedback thus getting closer to the deliberate practice. However if such activities are not done under supervision or constant feedback and guidance they could easily be deviated to the entertainment side of the curve than education. Nothing wrong with enjoying or having fun but excellence is never a product of mere enjoyment. Assignments and in particular assigning specific mentor/teacher to a student is a part of medical school as well. Those actions are of most value when the assignments are individualized (or at least modified later as per the student’s need) and the same teacher is assigned for a longer period of time when he not only evaluates but also understands the particular student as a whole and mould him/her in the best way possible.

In conclusion, the principles of excellence and expert performance are universal. The principles that Lionel Messi uses to become a great footballer is of not much difference than you use being a doctor, teacher, engineer, lawyer or anything on that regard. The only difference might be is that in much subjective field it’s difficult to rank the expert and superior ones with concrete criteria. Activities or hobbies as mundane as gardening or cleaning the house can too be greatly improved using the same principles. In this present era of human civilization one can firmly argue with countless scientific evidences that anyone who has or ever will attend great heights will never ever do so without working as hard as or harder than anybody else. It’s your choice whether you work deliberately to make it happen in life or live in denial blaming shortage of talent and your genes letting life happen to you.

Books read to create the article:

  1. Peak: Secrets from New Science of Expertise- Anders Ericson and Robert Pool
  2. Talent is Overrated: Geoffrey Colvin
  3. The Talent Code: Daniel Coyle
  4. Grit: Angela Duckworth
  5. Deep Work: Cal Newport
  6. The Practicing Mind: Thomas M.Sterner
  7. The Art of Learning: Joshua Waitzkin


Patan Academy of Health Sciences (PAHS)

MBBS 4th Year


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