There has been an interesting change in medical
education over the time that I have been a faculty member. I am sure that many
people involved in education have seen the same change. It appears that the
phenomenon occurs across multiple, different disciplines. The change is related
is how we use student satisfaction data. And even more specifically, what
importance is put on student satisfaction data, how it’s used for curricular
change, and how it is used to drive the curriculum.
I had a lot of great experiences when I
was a medical student. But, I had one really interesting (not-so-great) experience.
We had a professor who was very well-liked. He was a great teacher and a
student advocate. He was one of those teachers that was always available to
meet with a student who didn’t understand concepts or to do individual tutoring
sessions. He was very personable. He was also a great lecturer, he always
delivered content that was relevant and useful. His test questions were
consistent with the lectures that he gave and the information that was in the
lectures that he gave.
As a student, he was what most of us
thought of as the gold standard for a faculty educator. But he was not a
researcher. And in many academic departments and medical schools, you have to
be a researcher first, and a teacher second. If you don’t get enough research
grants, then your job is at risk. And that’s what happened in this situation:
his contract was not renewed, because he did not receive tenure.
My medical school class was the group of
students that worked with him the most because of the course that he taught. We
were very upset by the school's decision. We wanted to do something to express
our dissatisfaction with this result. He was one of our best teachers. We did
not think it was right to get rid of one of our best teachers. So, we wrote a
very professional letter to the Dean of the medical school, expressing our
feelings about this decision. The entire class signed it. There were over a
hundred people in the class, everyone signed this letter. Then our class
president took this letter, you can call it a petition, I guess, but it was
really just a letter, to the Dean of the medical school.
What happened next is shocking to me
now, but at the time it was not surprising. The Dean basically threw the class
president out of his office and told him never to come back. He said something
to the effect of “This is my medical school, and I’m charge and the students
don’t have any say in what goes on.” Actually, at the time, there was a story
going around that he said, “If you complain about anything else, I’ll break
your kneecaps,” or something like that. But that may have just been a story
that was made up by med students afterwards.
Fast forward to 2014... For every course that we deliver in our
medical school (and in every medical school that I know of) we ask the students
to comment on the process. We ask them
to comment on the policies that are in place. We ask them to comment on the
learning objectives and whether the content matched the learning objectives. We
ask them about the content of the course. We ask them a lot for their opinion
about their satisfaction with the curriculum. There’re some really good things
about this. Clearly, the dean’s response to my class’s dissatisfaction was not
a great response. But I think it is possible for the pendulum to swing too far
the other direction.
In a lot of medical schools, students
have this idea that they are helping to determine the curriculum. I think that
is a dangerous and, in many ways, nonsensical idea. In addition, the LCME looks
at student satisfaction on the Graduate Questionnaire, a survey that is sent
out to all medical students after graduation. In the accreditation
visits for each medical school, the LCME uses that data to determine
accreditation for the medical schools. Again, this is a very dangerous
proposition in many ways.
Now, don’t get me wrong. I am very
interested in student satisfaction data. But the data that I think that they
should be giving us is how the content was delivered, how accessible were the
faculty, did they follow the policies that we have set forth for grading? Did
the questions that were on their test match up with the content that was
delivered during their lectures? Was their lecture style appropriate? Did they
understand the lecture? Were their slides helpful and additive to the lectures?
Those are the kind of questions that student satisfaction data would be pretty useful
in answering. And we do some of that.
But often, we ask them other questions.
For example: do you think that the information in this course will help you to
be a better doctor? That question bothers me a lot. I really have trouble
seeing how a medical student would know the answer to that or how their answer
to that would change what I want to do as far as a course that I am teaching. I
see medical students in their comments, write things like, “the information in
this lecture is not important,” or “the information in this course is fluff.”
When I think about that, I wonder. Does a student have the framework to make
that call?
One of the things that is important for
faculty and course directors and medical schools to do is to think about what the
curriculum should look like. What information do you want the students to learn?
To some extent, that is driven by the national examinations, like USMLE. There
is content that every student will be tested on in the national standardized
tests. The curriculum needs to do a good job of preparing the students to take those
tests. But how the other pieces of the curriculum are emphasized should be the
judgment of the faculty.
It often seems like, students are giving
their opinion. That is opinion is based on what they think is important, but
with little background or context. So for instance, we had a student comment that
said, “I didn’t like going to this clinical site.” I thought it was an interesting
comment. We specifically chose that as a clinical site for all the students,
because we wanted them to have the experience. It was an underserved practice.
We wanted them to be exposed to a clinic in an underserved area so that they might
see how it could be useful to them in their future practice. Most of the
students really got that. But occasionally, there’d be a student who just didn’t
really think that that was important. So I think, okay, so you didn’t think it
was important, but I do.
Another thing that students comment on
in satisfaction surveys are things that are outside of their expertise. It is often
comments like “I don’t understand why this test counts for so much of my grade.”
I think it should count for that much of your grade. It doesn’t make any
difference that the student doesn’t agree with me.
I say all of this to come back to the
curricular review and development process. Every course in medical school should
be evaluated on a regular basis. The satisfaction surveys that students do are
given a lot of weight. If students make a lot of negative comments, or there
are several things that they do not like, there is a push from the Dean’s
office to look at those comments. The administration may encourage the director
to change their course in some way. That is problematic, because it takes the
power of determining the direction of the medical curriculum away from the
faculty and gives it to students. The faculty are the most experienced and most
able to determine what the curriculum should look like but this gives curricular
control to the least experienced and least able to make decisions, the medical
students.
I’m not advocating that we should go
back to the place where the dean can kick you out of his office and tell you he
doesn’t want you to ever come back, but I do think that it’s important for the
medical school faculty to drive the curriculum. Student comments should be
limited to the delivery and the process and the policies, and stay out of what
the content is and how that content is weighted.
