Last year, I gave a speech in Chatuaqua, NY, about restructuring schools -- about different ways of organizing learning and teaching in order to get more students to be successful. I cited models like the Boy Scouts and a school in Cologne, West Germany, where students work together in teams and are given responsibility for directing their own education, where academic learning occurs primarily through analyzing and solving real problems and where teachers rarely lecture and instead work more like coaches.
Typically, when I give a speech like that, lots of people are enthusiastic about the vision but doubt that these ideas could ever work in reality. But that day in Chatauqua, something different happened. A member of the audience came up to me and said he was a physician and that the ideas I was talking about were already being practiced in a few medical schools around the world. The pioneer in this approach, he also told me, was McMaster University's School of Medicine, in Hamilton, Ontario, Canada. And that's how it happened that, last week, I went to a medical school to further my study of the anatomy of public education.
Unlike most medical schools, McMaster' s has no formal classes or exams, its faculty rarely give a lecture and its students don't have to master the basic medical sciences before they're exposed to a real medical problem or patient. Instead, they tackle clinical problems and practice behaving according to the professional norms of medicine from the first day they arrive. McMaster' s program is also different from most other medical schools because it runs for three rather than four years. Sound like a snake-oil diploma mill? Perhaps. But the fact is that McMaster' s students do as well as traditional medical students on their licensing exams and in their careers, and a number of medical schools are implementing similar models.
How does this restructured medical school work? The school is too rich to describe in detail, but here are some highlights. The one hundred or so students who are admitted each year are divided into five or six groups, and each group is assigned a tutor. The students meet in their tutorial groups about two times a week for two to four hours a session, depending on the discussion of the group. Tutorials are organized around major biomedical problems that can't be solved without understanding physical, biological and behavioral principles, how to collect data and how to evaluate evidence. The problems may be presented in written form, through audio-visual or computer technology or by a simulated "patient."
Of course, first day medical students know few or none of the principles or skills necessary to solve the problems presented to them in the tutorials. But solving the problems isn't the purpose of the tutorials, at least not initially. Instead, the students are supposed to figure out what they need to know to frame the problem and break it down into manageable parts and what hypotheses they'll need test the order to see if their initial impressions are right -- just like in the real world. Although the tutor may be tempted to tell the students that the problem first requires knowledge of anatomy and then lecture them on the subject, that's not the tutor's job. The tutor is there to run the discussion and keep the students from straying too far afield as they consider what they must know to solve the problem.
The students are next expected to follow up on their tutorial discussion and start acquiring the knowledge and skills they need for the problem. They've been trained by the school to use the print and non-traditional materials of the library as well as community resources, and they also have the right to call on faculty members for additional information, tutoring or even for a conventional lecture. Some of the students work with their peers, others work individually. But by the next tutorial, they're all supposed to be prepared to demonstrate orally and in writing their progress toward understanding and solving the problem. One student may present a report on what the textbooks have to say about similar problems and how to diagnose and treat them. Another student may challenge him with findings from more recent journal articles on anatomy and her observations of a patient. A third student may present the research she's conduced that indicates that some of the group's initial analyses and hypotheses were dead wrong.
And so the discussion goes, with the tutor helping to identify the strengths and weaknesses of the presentations and suggesting ways to overcome the difficulties encountered in understanding the problem. Then it's off to a new round of self-directed learning and observations until the tutor believes it's time for the group to go on to the next clinical problem, and the cycle begins again.
How do students know how well they're doing? There are no formal tests, but in fact students are evaluated at least twice a week by their peers and by the tutor (who also prepares a written evaluation). Since the success of the group depends on each student's efforts, there's considerable peer pressure to work hard. It's also hard to fool anyone about what you know because your tutorial presentations are sure to give you away. And, if students are still unsure about how they measure up, they can do a selfevaluation with traditional medical school tests the school keeps on file.
What did I learn from my brief career in medical school? First and foremost, it further encouraged my belief in the possibilities of restructuring public education. Still education is not like medicine, public school students are not like medical students and McMaster' s philosophy and curriculum are not for everyone. But if medicine, which still enjoys public confidence, is willing to experiment with new ways of organizing learning and teaching, why can't our troubled school system? If medical education is exploring the idea that different students learn in different ways and more than one model of education may be necessary, why can't our school system? If medical students can practice with reallife problems in real-life ways during the course of their education rather than after it, why can't more public school students? And if medical schools can take risks to save more patients, then can't we do the same for our students?