What would William Osler think of Clinical Education

What would William Osler think of Clinical Education in Japan today? Linda Snell MD MHPE FRCPC FACP Centre for Medical Education & Department of Medicine, Mc. Gill University, Montreal, Canada Visiting Professor, IRCME, 2006 -7 University of Tokyo

Why this topic? q Osler - Canada connection q Osler - Mc. Gill connection q Osler – Kaga connection

Purpose q To educate q To motivate q To inspire q To change

My ‘sources’ q q Curriculum descriptions and curriculum reports Reading q q Medical Education literature * “The Quotable Osler” ** K Kaga proposals re curriculum change Discussions q q q Students Faculty Japanese medical educators Observation of & participation in clinical *Kozu. Acad. Med. 81(12): 1069 -75, Dec 2006; Teo. Med. Educ. 41: 302 -8, Mar 2007 education q **Eds Silverman, Murray, Bryan. ACP. 2003

Clinical education in Japan 1. Curriculum 2. Bedside learning 3. Postgraduate education 4. Life-long learning q q Strengths Challenges Selected points, not an organized overview! q Osler’s thoughts Osler the person

Clinical Education, not Clinical Teaching q Teaching and the teachers q Learning and the learners q The clinical context q The curriculum

Clinical Education 1. Curriculum 2. Bedside learning 3. Postgraduate education 4. Life-long learning

The curriculum q q Discipline-based – affects learning of clinical medicine Late clinical exposure Clerkships short duration, many subspecialty areas Emphasis on memory & recall, vs understanding and development of problem-solving skills q q q PBL (4/5) Core curriculum (4/5) Integrated lectures OSCE as part of CAT Free quarter Exposure to community hospital-type patients (4/5)

Osler: Was not convinced that clinical work should begin at the onset of medical school “I do not think that, with our present congested curriculum, it is an advantage to begin clinical work at once. It may be good for the student morally, but I am sure it is bad for him intellectually, and he gleans a heterogeneous collection of isolated halfunderstood experiences, instead of an orderly sequence in which the acquired knowledge of laboratories is brought to bear on the problems of disease. ”

Insisted students go to bedside and participate in hands-on care “take the student from the lecture room, take him from the amphitheatre – put him in the outpatient department – put him in the wards. ”

Osler: recognized that a combination of concurrent ‘book learning’ and clinical learning was effective “To study the phenomena of disease without books is to sail an uncharted sea. Whilst to study books without patients is not to go to sea at all. ” "The student begins with the patient, continues with the patient and ends his studies with the patient, using books and lectures as tools as means to an end”

Osler: Emphasized ‘methods’ (thinking skills) rather than the acquisition and regurgitation of facts “The student needs more time for quiet study, fewer classes, fewer lectures, and above all examinations should be lifted from his soul. ” “We try to teach the student too much. Give him good methods and a proper point of view, and all other things will be added as experience grows. ”

The curriculum q q Discipline-based – affects learning of clinical medicine Late clinical exposure Clerkships short duration, many subspecialty areas Emphasis on memory & recall, vs understanding and development of problem-solving skills q q q PBL (4/5) Core curriculum (4/5) Integrated lectures OSCE as part of CAT Free quarter Exposure to community hospital-type patients (4/5)

Clinical Education 1. Curriculum 2. Bedside learning 3. Postgraduate education 4. Life-long learning

Bedside education q q q Students observe – little ‘hands-on’, passive “Patients do not want to see students” Competing demands on teachers - decreased time with rounding team q q Clinical skills labs Popular professors teach critical thinking & clinical reasoning

Osler: Pioneer of bedside teaching – recognized its importance for learning “Medicine is learned at the bedside and not in the classroom … Live in the ward. ”

Emphasized the importance of taking a good history, doing a thorough exam, spending time with the patient “…It is a safe rule to have no teaching without the patient for a text, and the best teaching is that taught by the patient himself”

Osler knew active experiential was effective learning “Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know by practice alone that you can become an expert. Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from the book. See, then reason and compare and control. But see first. ”

Osler recognized the patient’s contribution to learning The patient was made to feel that he was helping in the education of medical students, and that the student was his doctor… Dr Osler always created a friendly atmosphere … The student was seeing in Dr Osler a demonstration of the best sort of physicianpatient relationship and was gaining invaluable preparation for his own independent clinical work” Christian HA Arch Intern Med 1949

Osler: teaching on the wards is a pleasure not an obligation “The best life of the teacher is in supervising the personal daily contact of the patient with the student on the wards. ”

Osler thought that outstanding teachers with practical experience should be department Chairs University departments should be “in the charge of men who have, first, enthusiasm, that deep love of a subject, that desire to teach and extend it…; secondly, a full personal knowledge of the branch taught, not second hand from books but from living experience …”

Bedside education q q q Students observe – little ‘hands-on’, passive “Patients do not want to see students” Competing demands on teachers - decreased time with rounding team q q Clinical skills labs ‘Popular teachers’ try to teach critical thinking & clinical reasoning

Clinical Education 1. Curriculum 2. Bedside learning 3. Postgraduate education 4. Life-long learning

Postgraduate education - PGY 1 -2 q q q Emphasis on technical aspects Little exposure to outpatients Didactic education varies: (conferences, grand rounds, halfdays, M&M rounds) ‘Core competencies’ not formally taught Entry level low clinical skills q q q 2 year internship emphasis on hands-on skills Learning ‘hierarchy: interns taught by residents … Emphasis on primary care: GIM, general surgery & EM q Objectives: q q q doctor patient relationship; collaborative skills; social, organizational &

Osler: Created first residency programs q Live in the hospital “Postgraduate study has always been a feature of our profession” q Hierarchical & Pyramidal “No man can teach successfully who is not at the same time a student”

Osler: Recognized the value of experience as a learning method “The important thing is to make the lesson of each case tell on your education. The value of experience is not in seeing much, but in seeing wisely. ”

Osler: Promoted the importance of learning general medicine “The art is getting longer and longer, the brain [of the learner] has its limits…the time is too short for a man already burdened to the breaking point, to study any specialty from the standpoint of the specialist. ”

Osler: Emphasis on learning to care for whole patient, and role modeling the doctor patient relationship the learner “should learn how to study disease and how to treat it, or rather, as I prefer to teach, how to treat patients. ” “Every patient you see is a lesson in much more than the malady which he suffers. ” “Our study is man, as the subject of accidents or disease. ”

Clinical Education 1. Curriculum 2. Bedside learning 3. Postgraduate education 4. Life-long learning

Life-long learning q q q Reflection rarely taught Skills of LLL not role modeled or explicitly discussed Journal clubs and EBM discussion uncommon q Emphasis in internship in ‘learning from cases’

Osler: Recognized the ‘information explosion’ and the need to keep up to date “Medicine is a “progressive science, day by day receiving fresh acquisitions, opening up new fields for investigation, and it will be your duty … to keep pace with this progress. ”

Osler was a life-long learner “It is a good many years since I sat on the benches, but I am happy to say that I am still a medical student, and still feel I have much to learn”

Osler: Believed that ongoing education essential for the life of a practitioner “The hardest conviction to get into the mind of the beginner is that the education upon which he is engaged is not a college course, not a medical course, but a life course, for which the work of a few years under teachers is but a preparation”

Osler: Originated the first journal club “A physician who does not read books and journals … who does not read one or two of the best weeklies and monthlies, soon sinks to the level of a cross-counter prescriber”. “For the general practitioner a well-used library is one of the few correctives of premature senility…”

Osler the person

Osler as a role model q ‘Humanitarian and teacher’: taught medicine as a humanity and an art, as well as a science q Renaissance man q Personal qualities

Art and Science of Medicine “The practice of medicine is an art, based on science. ” “The practice of medicine is an art, not a trade; a calling, not a business: a calling in which your heart will be exercised equally with your head”

Renaissance man “Before going to sleep, read for half an hour, and in the morning have a book open on your dressing table. You will be surprised to find how much can be accomplished in the course of a year. ” “The young doctor should look about early for an avocation, a pastime that will take him away from patients, pills and potions …anything will do so long as he straddles a hobby and rides it hard. ”

Personal qualities Compassionate Respectful Caring Tolerant Sense of humour Love of fellow man Humble Warm

Kaga recommendations for medical education reform q Standardized clinical curriculum Integrate basic science & clinical medicine: “facts of disease should relate to clinical presentation & reasoning” Small group tutorials with case discussion for clinical links Long core clerkships: more time learning clinical practice Exposure to outpatients – continuity q Importance of bedside learning q q 1969

Last words “Medicine is a most difficult art to acquire. All the college can do is teach the student principles, based on facts in science, and give him good methods of work. These simply start him in the right direction…”