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Richard B. Gunderman

Achieving Excellence
in Medical Education
Second Edition
Author
Richard B. Gunderman, MD, PhD
Indiana University
Indianapolis, IN
USA

ISBN 978-0-85729-306-0 2nd edition e-ISBN 978-0-85729-307-7 2nd edition

ISBN 978-1-84628-296-6 1st edition (HB) ISBN 978-1-84628-813-5 1st edition (PB)
e-ISBN 978-1-84628-317-5 1st edition
DOI 10.1007/978-0-85729-307-7
Springer London Dordrecht Heidelberg New York
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Preface

A celebrated historian, a man who had won many awards for his writing,
was invited to give an address at a great American university. In conjunc-
tion with his visit, the university’s former president, a highly distinguished
scholar and leader in his own right, invited him to lunch. As the two were
dining, the former president asked the historian whether he had majored
in history in college.
“No,” the historian replied, “I was an English major. In fact, I did not
take a single history course until my very last semester.”
“That must have been quite a course,” the former president replied.
The historian paused, looking at the trees outside the windows,
“Actually, I do not remember much about it. I cannot even tell you the
name of the instructor. He was not a faculty member, but a graduate
student.”
“So the course didn’t make much of an impression on you?” prompted
the former president.
“Actually, I was very inspired by something the instructor said on the first
day of class,” the historian replied. “He told us, ‘We are going to be studying
many different historical ages, events, and personages. As we do so, never for-
get that we are not just talking about names in books. We are talking about
real, flesh-and-blood human beings, people as real as you and I.’”
The historian again looked out at the trees. “That really impressed me. I
have never forgotten it. In everything I have written, I have always tried to
capture the sense that we are dealing with real people, who got up every
morning and laid their heads down every night. They were human beings
just like us, who bore children, buried their parents, and who were in turn
buried by their children. They gazed up at the very same sun, moon, and
starry night sky that shine now above us.”
“That’s a beautiful story,” the former president replied. “To which I
would add one coda. The graduate student who taught that course?”
“Yes?” said the historian.
“You’re looking at him.”
Henry Adams, one of the great American intellectual historians, once
wrote about teaching:
A teacher affects eternity; no one can tell where his influence stops.

v
vi Preface

Every educator was once a learner, and every learner becomes an edu-
cator. Whether we hold a faculty position or not, to practice medicine is to
be a teacher. For one thing, the title by which our patients know us, doctor,
comes from a Latin root that means teacher. Moreover, every interaction
with a patient or fellow health professional is an opportunity to teach. We
teach not only formally, with syllabi and curricula, but also informally,
through the questions we ask and the examples we set.
Everyone knows that we learners model ourselves, unconsciously as
well as consciously, after our teachers. We remember what we are assigned
to study, we mimic the styles and phrasings of those who taught us, and
when faced with difficult situations, we ask ourselves how our most
esteemed teachers would respond.
Yet we sometimes forget the profound impact of learners on educators.
There is a story about the behaviorist psychologist B.F. Skinner, whose
students at Harvard decided to test out the theory of behaviorism on their
instructor. During lecture, every time Skinner leaned to his right, the stu-
dents would feign boredom, looking out the window or putting their
heads on their desks. Every time Skinner leaned to his left, the students
would show great interest, hanging on his every word. By the midpoint of
the lecture, so the story goes, Skinner was leaning so far to his left that he
fell from the podium.
Do students care about what instructors have to teach and how they
teach it? Do they have learning objectives beyond the material that is
going to be included on the next test? Do they realize that excellence in
medicine has more to do with attitude, style, and philosophy than with
facts and rules? Do they see that it is less about downloading, storing, and
retrieving information than about imbibing and embodying character?
Do the members of the faculty come prepared to convey genuine curi-
osity, commitment, and excitement about their approach to health and
disease? Do the members of the student body come prepared not only to
memorize but to be challenged and inspired? What if faculty members
never really invest themselves in the teaching, instead just reading their
notes? What if students never really show up at all?
Education is like a dance, and it takes two to tango. Just because certain
curricular material was presented in class does not mean that a faculty
member truly fulfilled an educational mission. The mere fact that seats
were warmed does not prove that learners really glimpsed what is most
worth knowing.
Great education is like great jazz. To respond creatively in the moment
requires attentiveness, playfulness, and generosity. Like great medicine, it
cannot be preprogrammed. There is no checklist or set of algorithms or
heuristics. Thank God it is not that easy! If it were, there would be no
illumination and no joy in it.
Preface vii

Instead, there is only the promise. If we pour ourselves heart and soul
into it, whether on the dance floor or the keyboard, at the bedside, or in the
classroom, we may catch a glimpse of it. We are talking about something
more than well-­formulated learning objectives, sound pedagogical tech-
niques, and high scores on high-stakes exams. We are talking about genius,
something worth recalling and celebrating for a lifetime, perhaps longer.
We are talking about a spark that we carry inside and, when conditions are
favorable, summon forth to light anew, like the passing of a torch.
The educator? The learner? The learner? The educator? You’re looking
at him. Who can say where such influence starts or stops?
The purpose of the second edition of this book is to serve as the cata-
lyst for reflection on excellence in medical education. What do we need to
attend to make the most of the opportunities before us—as both educa-
tors and learners? What does real excellence in medical education look
like, and what would be necessary to achieve it? What steps can we take to
ensure that we pass on the torch of medicine burning a bit more brightly
than when it was handed to us, and help each succeeding generation to do
the same? It is my hope that each of these essays will serve as a starting
point for medical educators and learners to engage in just this sort of
conversation.
Acknowledgments

This book reflects the examples of many superb educators with whom I
have had the privilege of learning. Each has illuminated the art of teach-
ing in ways I am still struggling to articulate. They include Eric Dean,
David Grene, James Gustafson, Leon Kass, Leszek Kolakowski, Paul Nagy,
Robert Payton, William Placher, Mark Siegler, Norma Wagoner, and Karl
Weintraub.
Thanks also to a number of people who have collaborated with me on
projects on which this text draws, including Stan Alexander, Ken
Buckwalter, Steve Chan, Mervyn Cohen, Janu Dalal, Josh Farber, Ron
Fraley, Mark Frank, Darel Heitkamp, Adam Hubbard, Val Jackson, Ya-Ping
Kang, Hal Kipfer, James Nyce, Aslam Siddiqui, Jennifer Steele, Jordan
Swensson, Robert Tarver, Ken Williamson, and Steve Willing.
The Schools of Medicine and Liberal Arts at Indiana University have
provided a first-rate environment for this inquiry. I would like to thank
the deans of both schools, Craig Brater and Bill Blomquist, and the chairs
of radiology and philosophy, Val Jackson and John Tilley, for their sup-
port. Thanks also to Lenny Berlin, Phil Cochran, Mervyn Cohen, Bruce
Hillman, Steve Kanter, Bill Schneider, and James Thrall, and to Ruth
Patterson for dedicated contributions to our shared educational work
over many years.
Engaged learners are among the most effective educators, and I am
immensely grateful to the thousands of students at University of Chicago
and Indiana University who have taught me about teaching, as well as my
friends around the world who have afforded me delightful opportunities
to learn at their institutions. Finally, I extend heartfelt thanks to my most
enduring teachers, James and Marilyn Gunderman, and deepest gratitude
to my beloved wife, Laura, and our four wonderful learners, Rebecca,
Peter, David, and John.

ix
Contents

1 Education Matters . . . . . . . . . . . . . . . . . . . . . . . . .  1

2 Theoretical Insights . . . . . . . . . . . . . . . . . . . . . . . .  17

3 Understanding Learners . . . . . . . . . . . . . . . . . . . . .  41

4 Promoting Learners . . . . . . . . . . . . . . . . . . . . . . . .  59

5 Educational Excellence . . . . . . . . . . . . . . . . . . . . . .  75

6 Educational Technique . . . . . . . . . . . . . . . . . . . . . .  93

7 Obstacles to Excellence . . . . . . . . . . . . . . . . . . . . . .  105

8 Organizational Excellence . . . . . . . . . . . . . . . . . . . .  127

9 Center of Excellence . . . . . . . . . . . . . . . . . . . . . . . .  149

10 Educational Leadership . . . . . . . . . . . . . . . . . . . . . .  165

xi
1
Education Matters

All who have reflected on the art of governing mankind have been convinced that
the fate of nations depends on education.
Aristotle, Politics

Defending Education
Academic medicine is like a tripod, standing on three legs. One leg is patient care,
one is research, and one is education. Over the course of the twentieth century, the
emphasis placed on each of these missions changed. In recent years, education has
become the short leg of the tripod. More and more attention and resources have
been devoted to patient care and research, and education has languished. This is a
dangerous situation, in part because it threatens to destabilize both medicine and
the healthcare system. If the profession of medicine and the healthcare of our
society are to flourish, we need well-educated physicians.
These changes are admirably documented by Kenneth Ludmerer in his 1999
book, Time to Heal: American Medical Education from the Turn of the Century to
the Era of Managed Care. He presents a scholarly examination of the major trends
in US medical education during the century, as well as a critique of the effects of
managed care on medical education. Ludmerer traces out the historical forces that
have placed medical education at risk, and provides insights into the remedies
that will be necessary to restore education to its proper stature in the culture of
our medical schools.
To appreciate what happened in the twentieth century, it is important to know
what medical education looked like in the nineteenth century. Ludmerer reminds
us that US medical education looked quite different then. Medical schools were
proprietary organizations, meaning that they operated for a profit. A typical course
of study consisted of two 14-week courses of lecturers, the second merely repris-
ing the first. To get into medical school, it was only necessary to be able to afford
the tuition. Many matriculating students were illiterate. Patient care was not part
of the curriculum. As a result, patients often suffered when graduates began “prac-
ticing” medicine.
Abraham Flexner’s 1910 report, Medical Education in the United States and
Canada, spurred significant changes (Fig. 1.1). Flexner called for radical reforms,

R.B. Gunderman, Achieving Excellence in Medical Education, 1

DOI: 10.1007/978-0-85729-307-7_1, © Springer-Verlag London Limited 2011
2 Achieving Excellence in Medical Education

Fig. 1.1 Abraham Flexner (1866–1959). Though Flexner had not attended medical school or
even earned a graduate degree, his 1910 report served as a catalyst for broad and rapid change
in medical education, including the closing of many medical schools and the reorganization of
both basic science and clinical teaching at those that survived. Through his work with the
Rockefeller Foundation General Education Board, Flexner helped to raise and direct vast sums
of money to institutions that followed his recommendations. In 1930, Flexner also founded
one of the most significant scholarly communities in the US, the Institute for Advanced Study
in Princeton, New Jersey, serving as its first director through 1939 (Courtesy of Wikimedia
Commons)

including basing all medical education in universities, which he believed would

provide the resources necessary to learn the scientific foundations of medical
practice. Of greater concern to Flexner than the basic medical sciences, however,
was clinical care. Many university-based medical schools were doing an adequate
job of teaching sciences such as anatomy, physiology, and pathology. At virtually
none, however, were medical students learning well how to care for patients.
Flexner argued that students had to make the transition from a passive role listen-
ing to lectures to an active role actually helping to care for the sick.
The only way, Flexner argued, that students could learn how to care for patients
was by caring for patients. They needed to do it themselves, not merely hear others
talk about it or watch others do it. To do this, medical schools needed to be based
in teaching hospitals. Flexner cited as his model the fledgling Johns Hopkins
University School of Medicine, which had been founded several years after the
Education Matters 3

Johns Hopkins Hospital in Baltimore. Hopkins was the site where luminaries such
as the three Williams, William Osler, William Halstead, and William Welch had
introduced such contemporary staples of medical education as medical student
clerkships and postgraduate training through internships and residencies. By
allying medical schools and hospitals, Flexner argued, medical students would
receive a robust education that truly prepared them to provide excellent care to
the sick.
American medicine embraced Flexner’s advice. The proprietary schools were
rapidly replaced by 4-year, university-based medical schools that evenly divided
the curriculum between basic medical sciences and clinical experiences.
This was the heyday of education in US medical schools. True to their status as
schools, medical schools treated education as their principal mission, to which
patient care and research were subordinated. Patient care and research were
important, but education was the defining mission. Community hospitals could
provide patient care, and biomedical research could be carried out in the basic
science departments of universities and by research institutes and private indus-
try, but only medical schools could produce physicians. The primacy of education
among the missions of US medical schools lasted at least until World War II.
In the two decades that followed World War II, the focus of US medical schools
shifted toward research. There was huge growth in the funding of research, and
many faculty members began to think of themselves less as teachers of future
physicians than as investigators expanding biomedical knowledge. Research
became the most prestigious track on which a faculty member could be promoted
and receive tenure. Medical schools and their deans began to keep score less by the
quality of education they offered and more by the quality of their research and the
size of their research budgets.
Beginning in 1965, another sea change began. As part of President Lyndon
Johnson’s Great Society initiatives, the legislation establishing Medicare and
Medicaid was passed. Suddenly, the charity care that medical schools had tradi-
tionally provided, as a way to educate the medical students, became a viable source
of revenue in its own right. Moreover, research was generating new and expensive
healthcare technologies, such as the CT scanner. As the US healthcare budget
mushroomed, medical schools began to shift their focus from research to patient
care. In the early 1960s, Ludmerer notes, medical schools derived only about 6% of
their income from the private practice of medicine. The social contract between
medical schools and their communities meant that the medical schools would
care for the poor in exchange for training the next generation of physicians. Poor
patients would get free care, and medical students and residents would have “clini-
cal material” to learn to practice medicine.
Beginning in the 1960s, this changed radically. Tens of millions of indigent
patients were converted into paying patients, and healthcare as a business began
to explode. Patient care, which formerly generated only 6% of the US medical
school revenues, soon grew to over 50%, substantially exceeding both research
and education. With the increase in revenues, the size of medical school faculties
mushroomed as well. Between 1965 and 1990, the full-time faculty of US medical