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 Medical Education:
A Dictionary of Quotations

KIERAN WALSH
MB, BCH, BAO, DCH, FHEA, FRCPI, FAcadMed
Clinical Director, BMJ Learning

Foreword by
DR FIONA GODLEE
Editor, BMJ

Radcliff
ffe Publishing
London • New York
Radcliff
ffe Publishing Ltd
33–41 Dallington Street
London
EC1V 0BB
United Kingdom

www.radcliff
ffepublishing.com
_____________________________________

© 2012 Kieran Walsh

Kieran Walsh has asserted his right under the Copyright, Designs and Patents Act 1988 to be
identifi
fied as the author of this work.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system
or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise, without the prior permission of the copyright owner.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library.

ISBN-13: 978 184619 548 8

The paper used for the text pages of this book

is FSC® certifi
fied. FSC (Th
The Forest Stewardship
Council®) is an international network to promote
responsible management of the world’s forests.

Typeset by Darkriver Design, Auckland, New Zealand

Printed and bound by TJI Digital, Padstow, Cornwall, UK
 Contents
Forewordd v
About the authorr vii

Introduction 1

Curriculum 3
1 Curriculum development 3
2 Selection 16
3 Basic sciences 24
4 Undergraduate medical education 27
5 Postgraduate medical education 47
6 Continuing professional development 58
7 Revalidation 71
8 Assessment 75
9 Feedback 93
10 Evaluation 96
11 Medical education research 103

Learning 110
12 Problem-based learning 110
13 Simulation 116
14 E-learning 119
15 Interprofessional education 123
16 Learning from experience 127
17 Learning from patients 135

Themes 149
18 Arts and humanities 149
19 Professionalism 156
iv CONTENTS

20 Ethics 165
21 Knowledge and wisdom 171
22 Competence 191
23 Behaviour 195

Teaching 200
24 Teachers and teaching 200
25 Lectures 219
26 Supervision and mentoring 225
27 Leadership and change 230
28 Educational environment 234
29 Ambulatory care and general practice 244
30 Cost and value in medical education 249
31 Future 256
 Foreword
Time may be gained by the simple and common-sense process of striking out of the
curriculum teaching that oppresses and bewilders the student, that distracts his
attention from the real object of his study, that loads his memory without training
his intellect.
—Robert Barnes

Robert Barnes’ words are likely to ring true with any twenty-fi first century medical
educator. Ideas for creating a leaner curriculum, developing students’ intellects, and
thinking about the real objectives of a course could all spring from a modern primer
on medical education. So it’s a surprise that Barnes, Obstetric Physician to St George’s
Hospital, was writing in 1875, and it’s tempting to ask why innovation in medical
education can take so long. The quotes in this book give some answers.
One reason for the way medical education has developed over the past 100 years
is that heads of traditional medical school departments – anatomy, physiology, bio-
chemistry – clung to their share of the curriculum at all costs. Curriculum reform
became a war. But as John Last wrote (p. 9) ‘the war for time and students’ minds is
a sad, futile, self destructive activity in many medical schools.’ The
Th pace of reform
wasn’t helped by the inability of many medical educationalists to manage change
and drive forward innovations, especially in the UK. According to George Pickering
(p. 101) ‘no country has produced so many excellent analyses of the present defects of
medical education as has Britain, and no country has done less to implement them.’
Another problem may have been that we were working on the wrong raw materials.
Selection for medical school has always been a bone of contention (and always will
be) but as Nicholas Gold points out (p. 18) selection has tended to lay too much
emphasis on pure academic ability. ‘By recruiting intelligent strivers with retentive
memories medical schools may acquire some lateral thinkers with a capacity for
empathy, but they would be there by accident rather than by design.’
Change came eventually and brought with it many of the features we now take for
granted. Aftfter the 1970s problem-based learning spread quickly throughout medical
schools in the Western world and further afi field. With it came small group teaching
and as Yvonne Steinert says (p. 116) ‘the opportunity for students to become actively
involved in the process of learning.’ Modern technologies have also brought high
fidelity simulation and e-learning. And research into medical education has started
to build an evidence base so we now know much more about what works and what
doesn’t. Medical educational research has had to fight its corner against scepticism
from those with a background in scientific fi research. Jill Morrison (p. 106) articulates
this particular battleground when she asks: ‘why do clear thinking clinicians and
researchers sometimes apply illogical thought to education?’ The growing number
of medical education journals and a burgeoning literature will hopefully see such
illogical thinking consigned to history.

v
vi FOREWORD

This book gives a fascinating insight into medical education – directly from the
pens of many leaders who have shaped it. It’s heartening that many of the quotes
come from late twentieth and twenty-fi first century educators. As Jennifer Leaning
wrote (p. 232) ‘Hippocrates and Maimonides still abide, but the vast changes in situ-
ation and circumstance since they spoke create the need for other canons.’ Let me
end with one of them: Peter Richards, Dean of St Mary’s Medical School, London
from 1979 to 1995 (p. 42):
The greatest challenge is to inspire students to curiosity, to fan the flames of their own
enthusiasm and the empathy which goes with it. All else will then fall into place.

Dr Fiona Godlee
Editor, BMJ
April 2012
 About the author
Dr Kieran Walsh is Clinical Director of BMJ Learning, the education service of the
BMJ Group. He is responsible for the editorial direction of the online learning serv-
ice and for BMJ Masterclasses (face-to-face learning meetings) and onExamination
(the assessment division). He has written over 200 articles for publication, mainly
in the field of medical education, and he has written the first-ever book on cost and
value in medical education. He has worked in the past as a hospital doctor, specialis-
ing in neurology and the care of the elderly.

vii
To Sarah Jane, Tommie Jack and Catie Sue, without
whom this book would not have been written
 Introduction
The wisdom of the wise and the experience of the ages are perpetuated by
quotations.
—Benjamin D’Israeli

Medical education is a vitally important discipline. Today’s students are tomorrow’s

doctors and the quality of education that they receive will have a key influence fl on
healthcare of the future. Medical education has developed enormously in the past
decade with the emergence of evidence-based teaching techniques, outcomes-based
curricula and valid and reliable assessment methods. Yet medical education will
never be an exact science – it will always depend on enthusiastic teachers and ambi-
tious learners who are hungry for new knowledge and skills. At a time when doctors
and other healthcare professionals bemoan low morale in the profession, the one
thing that can still generate enthusiasm among doctors is teaching and learning. Th This
book is intended to encourage and inspire teachers and learners alike. If it makes
even just one teacher or learner smile with recognition and return to a burgeoning
curriculum or problem-based tutorial with renewed vigour, then it will have suc-
ceeded in its aim.
Medical education has had a long history. Teachers have handed down knowledge
and learning for millennia and many have captured the essence of medical education
in the written and spoken word. The past 30 years have seen a blossoming of medi-
cal education research and we may be on the verge of truly evidence-based practice.
However, it can be useful to remind ourselves of the timeless nature of many of the
problems we continue to struggle with, and we can oft ften do this through reading the
words of the old masters. This alone is reason enough to put together a compendium
of quotes on medical education.
Quotations from any field of interest can be tricky and medical quotations are no
exception. Rick never did say ‘play it again, Sam’, nor did Marie Antoinette say ‘let
them eat cake’. People inevitably get misquoted or quoted out of context, and it can
sometimes be diffi
fficult to tell if someone is being serious or ironic. In this book I have
done my best to make the quotes as accurate as possible and to attribute them to the
original source. If there are any failures in accuracy, they are my own. If there are
successes that make you laugh or raise an eyebrow or have a light-bulb moment, they
are down to the many speakers, authors, editors and publishers without whom this
book could not have been written. Particular praise must go to the publishing staff ff
of the BMJ,J Journal of the American Medical Association, Medical Education, Medical
Teacherr and Radcliff ffe, all of whom were generous with both quotes and encourage-
ment. Thanks also to Edward Farrow for his help with categorising the quotes.
This book was written in three phases. The first phase involved writing a proposal
and making the case for the first book of quotations dedicated to the subject of medi-
cal education. My pitch was simple, being that medical education has always been

1
2 MEDICAL EDUCATION: A DICTIONARY OF QUOTATIONS

and always will be about one thing: people. The Th purpose of the book is to celebrate
all those involved in medical education, be they teachers, learners or patients. People
are defifined by their words and it is to be hoped that the quotes in this book show the
humanity of all those involved in medical education, as well as showing their wit and
insight and occasional frustration and anger.
The second phase involved writing and editing. That started easily enough but
Th
then gradually became harder. When I first started writing I was happy to take any
quote from any source, but as the work progressed I started to get choosy. Is a quote
still a quote when it comes from a committee or a learned council or a college? Is it
still a quote when it comes from two authors rather than just one? Midway through
writing I decided that I would exclude all examples of writing by committee and any
examples suff ffering from multiple author syndrome. Committees tend to produce
worthy but turgid prose, and the more authors involved, the more conservative and
guarded statements tend to be. What all the quotes in this book have in common –
whether you agree with them or not – is that they are examples of individuals who
have raised their head above the parapet, saying something controversial or funny
or just plain obvious.
The third and final phase involved adding finishing touches and, as with any
labour of love, there is a tinge of sadness at its conclusion. As the project has drawn
to a close, people have inevitably started to ask me who is my favourite medical edu-
cator and what is my favourite quote. One particular educator whom I have grown
fond of is Egerton Yorrick Davis. Davis was a retired US Army surgeon living in
Caughnawauga, Quebec, from where he conducted a prolific fi correspondence with
medical societies until his untimely death in a drowning accident at the Lachine
Rapids in 1884. He authored a controversial paper on the obstetric habits of Native
American tribes (the paper was suppressed and remains unpublished), and he was
the fi
first to report a case of penis captivus, indeed only 3 weeks aft
fter the first reported
case of vaginismus. If all this is starting to sound increasingly bizarre, it is because
none of this is true. Egerton Yorrick Davis was the invention of William Osler, who
wrote and published several pieces under this pseudonym and further propagated
the myth by signing Davis’s name to various medical conference attendance lists.
Osler is quoted over 30 times throughout this book and it came as a surprise that
the father of modern medical education, the man who stares rather po-faced out
of sepia-tinged photographs, was in fact an inveterate prankster. Osler would have
perhaps approved of Mark Albanese when he said, ‘We are all human, and we have
been human for much longer than we have been professionals’. Osler is my favourite
educator but my favourite quote comes from Francis Peabody. In 1927 Peabody gave
his famous lecture on the care of the patient – he was only 47 years old and was dying
of metastatic cancer. In a wide-ranging address he spoke of the need to individualise
medical care, to make hospitalisation a less dehumanising experience and to care
better for patients with symptoms for which an organic cause cannot be found. Here
is how Peabody ended this lecture:

One of the essential qualities of the clinician is an interest in humanity, for the secret of
the care of the patient is in caring for the patient.
 Curriculum

1. CURRICULUM DEVELOPMENT

In 1987 and again in 1988 the General Medical Council (GMC) education committee reported
that British medical schools were having difficulty in achieving their educational objectives.
(The claim that medical schools actually had educational objectives came as a considerable
surprise to many working within them.)
Robin Fraser

For two generations we have been loading and loading this brief curriculum as if we
desired to teach many things ill rather than a few things well.
Thomas Clifffford Allbutt
Allbutt TC. An address on medical education in London: delivered at King’s College Hospital on October 3rd, 1905, at
the opening of the medical session. BMJ. 1905; 2(2337): 913–18.

Although there is no reason to suppose that learner-centred teaching cannot occur in a

curriculum-based teaching programme, there is a tendency for the curriculum to influ- fl
ence how things are taught in that it may structure teaching to ‘chosen’ areas and so may
lead to ‘convergent thinking’ rather than true exploration and learner centredness.
Tahir Awan
Awan T. Structured, curriculum-based group teaching or unstructured, learner-centred group approaches? Educ Prim
Care. 2009; 20(6): 462–7.

Any curriculum plan which disregards the nature of learning, and of the learners, is bound
to be ineffective.
ff
Raja Bandaranayake
Bandaranayake RC. How to plan a medical curriculum. Med Teach. 1985; 7(1): 7–13.

Time may be gained by the simple and common-sense process of striking out of the cur-
riculum teaching that oppresses and bewilders the student, that distracts his attention
from the real object of his study, that loads his memory without training his intellect.
Robert Barnes
Barnes R. An address on obstetric medicine and its position in medical education. BMJ. 1875; 2(758): 33–5.

What applies to the design of the curriculum as a whole applies to the individual
studies.
W Gordon Byers
Byers WG. The place of ophthalmology in the undergraduate medical curriculum. BMJ. 1922; 2(3209): 4–6.

3
4 MEDICAL EDUCATION: A DICTIONARY OF QUOTATIONS

I would suggest that, as the majority of us are destined to be general practitioners, general
practitioners of good standing should be well represented on our teaching bodies, and
the advantage of their experience be applied to the curriculum.
Ernest Carmody
Carmody EP. Education for general practice. BMJ. 1932; 2(3734): 224–5.

At present there is no method. The curriculum is the accidental result of multiple colli-
sions between vested interests in a variety of departments, held in check by the inertia
of tradition.
Bruce Charlton
Charlton BG. Practical reform of preclinical education: core curriculum and science projects. Med Teach. 1991; 13(1):
21–8.

Reforms such as increasing generalist training, increasing ambulatory care exposure,

providing social science courses, teaching lifelong and self-learning skills, reward-
ing teaching, clarifying the school mission, and centralizing curriculum control have
appeared almost continuously since 1910.
Nicholas Christakis
Christakis NA. The similarity and frequency of proposals to reform US medical education: constant concerns. JAMA.
1995; 274(9): 706–11.

I think that the emphasis laid on the division of the curriculum into pre-clinical and
clinical is unfortunate. The division is perhaps convenient in many ways, but it is wholly
artifi
ficial and educationally unsound.
GA Clark
Clark GA. The medical curriculum. BMJ. 1942; 2(4260): 259.

Th various subjects of the curriculum have developed as autonomous independent

The
compartments of knowledge; yet for medical education they must be viewed primarily
as diff
fferent facets of the same subject.
Henry Cohen
Cohen H. Medicine, science, and humanism. BMJ. 1950; 2(4672): 179–84.

The Malthusian problem for the curriculum is that the length of the curriculum is fixed
(or can grow by only slight linear increments) while the subject matter it could cover
grows exponentially.
Ken Cox
Cox K. Knowledge which cannot be used is useless. Med Teach. 1987; 9(2): 145–54.

To incorporate special study with general medical education is, therefore, to do injustice
to both; for general medical education, which already fully occupies the time set apart for
it, must be detrimentally curtailed or compressed to make room for the special study; and
the special study cannot be advantageously carried on while the foundations on which it
ought to rest have not been wholly laid down nor thoroughly consolidated.
James Crichton Browne
Crichton Browne J. The address delivered in the section of psychology. BMJ. 1880; 2(1024): 262–7.
 CURRICULUM 5

If it is this “Jack-of-all-trades” that is wanted, let us by all means go on as we are doing,

adding another year to the curriculum every now and again.
Hugh Crichton-Miller
Crichton-Miller H. “The student in irons”. BMJ. 1932; 1(3718): 680–1.

Now, the average student is a gentleman admitted to society; drinking, card-playing, and
midnight rioting, are no longer essentials in his curriculum; frequently he has secured for
himself the status of graduate or undergraduate of a university; more often
ft he has been
reared in a public school, and entering upon his technical education with all the rawness
and inexperience of a schoolboy, has nevertheless an intellect prepared for theoretical
instruction.
Edward Crossman
Crossman E. An address on the maintenance of the honour and respectability of the medical profession. BMJ. 1883;
2(1176): 61–7.

Will the [Edinburgh] declaration change medical education? Anyone familiar with the
kind of wranglings that precede the transfer of even a week of curricular time in an estab-
lished medical school will not be optimistic.
Colin Currie
Currie C. Global village fête. BMJ. 1988; 297(6648): 630.

There is abundant justifification, however, for the plea that the real object of the medical
curriculum, perhaps more than of any other educational discipline, should be to train the
student to observe, to think, and to form a reasoned judgement, and not to make confused
and evanescent records on his memory.
Henry Dale
Dale H. An address on the relation of physiology to medicine, in research and education. BMJ. 1932; 2(3753): 1043–6.

The expansion of knowledge is also not a new problem. Medical curricula of 100 years
ago also lamented that five years was not long enough to learn all that is needed.
Matt Doogue
Doogue M. Debunking one myth and perpetuating another. BMJ. 2002 January 20. Available at: www.bmj.com/
content/324/7330/173.1/reply#bmj_el_18941?sid=d5e693ea-0765-423d-ac1d-1c98624d8fdf (accessed 10 July 2011).

In my beginning is my end.
TS Eliot
East Coker, from Four Quartets. 1940.

Educational experiences designed to develop the intellect are not commonly offered ff
except in an additional year of study – though some schools make time for them by a
horizontally integrated curriculum which enables a core of basic knowledge to be acquired
quickly.
John Ellis
Ellis J. Editorial: 2. The present state of medical education in Britain. Med Teach. 1987; 9(3): 243–6.

Th great worry is that premed requirements and much of what is taught in medical school
The
has simply persisted without good justifi
fication by inertia and the potential energy barrier
that discourages curricular changes, no matter how meritorious.
Ezekiel Emanuel
Emanuel EJ. Changing premedical requirements: reply. JAMA. 2007; 297(1): 38–9.
6 MEDICAL EDUCATION: A DICTIONARY OF QUOTATIONS

Objectives are no more than a means to an end, but they are essential for an analytical,
logical and systematic approach to the education of future doctors.
Charles Engel
Engel CA. Controversy: for the use of objectives. Med Teach. 1980; 2(5): 232.

In the school curriculum of the medical student more emphasis should be given to the
prevailing dangers arising from the too-ready acceptance of the action and clinical value
of medicines conveyed through the pressing salesmanship by representatives of drug
houses, or convened in colourful advertisements which arrive by mail at unwarranted
prodigious cost.
William Evans
Evans W. Addiction to medicines. BMJ. 1962; 2(5306): 722–5.

In curricular innovation, as in the rest of life, I would contend that the way something is
done is oft
ften even more important that the act itself.
David Findlay
Findlay DJ. How to do it: strategy and tactics in curricular innovation. Med Teach. 1988; 10(2): 147–8.

One of the most diffi

fficult problems in revising course content in any discipline is the
establishment and maintenance of some systematic approach.
Lawrence Fisher
Fisher LA. What can be done about curriculum. Arch Dermatol. 1966; 93(5): 536–8.

What sound reason can be given for requiring the able and the less able, the industrious
and the less industrious, to complete practically the same course of instruction in the
same period of time?
Abraham Flexner
Flexner A. Medical education, 1909–1924. JAMA. 1924; 82(11): 833–8.

In 1987 and again in 1988 the General Medical Council (GMC) education committee
reported that British medical schools were having diffi
fficulty in achieving their educational
objectives. (Th
The claim that medical schools actually had educational objectives came as a
considerable surprise to many working within them.)
Robin Fraser
Fraser RC. Undergraduate medical education: present state and future needs. BMJ. 1991; 303(6793): 41–3.

Progress in medical education occurs slowly because it is generally envisaged in a fixed

fi
framework; the effort
ff to find more room for more subjects is frustrated by the diffi
fficulties
of omitting or contracting others.
Hugh Gainsborough
Gainsborough H. Medical education. BMJ. 1958; 2(5099): 795.

The teaching of professionalism in undergraduate medical education has tradition-

ally been entrusted to the hidden curriculum through transmission via respected role
models.
John Goldie
Goldie J. Integrating professionalism teaching into undergraduate medical education in the UK setting. Med Teach.
2008; 30(5): 513–27.
 CURRICULUM 7

Th strength of medical education is its integration of service and training.

The
Janet Grant
Grant J. The Calman report and specialist training: Calman report builds on the status quo. BMJ. 1993; 306(6894):
1756.

Then, in the latter part of the curriculum, it is nothing less than a scandal that a man
may be fully qualifi
fied and yet be absurdly ignorant of the most elementary principles of
hygiene, medical jurisprudence, and psychology.
Alfred Gubb
Gubb AS. The colleges and the M.D. degree. BMJ. 1885; 2(1299): 996.

At the present time, therefore, when the medical curriculum is being overhauled and
improvements made, not only as to the means of acquiring knowledge, but also as to the
tests of acquirement, it would be well to have the claims of public health attended to.
John Haddon
Haddon J. The teaching of public medicine. BMJ. 1890; 2(1542): 178–9.

To date much of the attention in OBE [outcome-based education] has focussed on the
specifi
fication of learning outcomes and less on the implementation of an OBE approach
in practice.
Ronald Harden
Harden RM. Learning outcomes as a tool to assess progression. Med Teach. 2007; 29(7): 678–82.

All training programmes should have some form of documented curriculum, ideally
developed with the assistance of a range of stakeholders and interest groups, and therefore
refl
flecting reasonable consensus on what the graduate of the training programme should
know and do.
Richard Hays
Hays R. An overview of clinical teaching issues. In: Hays R. Teaching and Learning in Clinical Settings. Oxford:
Radcliffe Publishing; 2006. pp15–28.

Another advantage gained from the study of medical history is the additional incitement
and encouragement it gives us in the scientific
fi pursuit of our profession.
Alexander Henry
Henry A. Lectures on the history of medicine. BMJ. 1860; 1(169): 219–23.

Yet, strange though it may seem, the teaching of the history of medicine is a novelty in
England.
Alexander Henry
Henry A. Lectures on the history of medicine. BMJ. 1860; 1(169): 219–23.

Social networks oft

ften underpin educational activities, especially those which are peer
led, but these may be disrupted by competition, and diff
fferences across the UK may lead
to divisions on curricula and training models.
Amanda Howe
Howe A. Thinking ahead: GP educators in England need to be planning for the NHS reforms. Educ Prim Care. 2010;
21(6): 352–3.
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