Background: Problems in Medical Education

Stephanie Brown Clark, MD, PhD

Our conversation started over a short article that appeared in the Journal of the American Medical Association (JAMA) by two physicians, Jacqueline Dolev and Irwin Braverman, and a museum educator, Linda Friedlaender.1 As we discussed this article, our conversation about the clinical diagnostic process of observation moved beyond observation to the complex process of clinical diagnosis itself and the challenges of teaching these skills to students.

As a medical educator, I realized that Dr. Braverman’s decision to take his residents to an art museum to work with art objects instead of to the bedside to work with patients broke the long tradition of medical education: the bedside is the where clinical skills like observation and diagnosis have always been taught. Braverman surmised that his learners had not successfully internalized these skills in their medical education. The bedside teaching that had worked for him as a physician-in-training in the 1960s did not seem to have worked as well for his students in 1998.


Knowledge and technology shape medical culture and influence the way that physicians are trained. Up to the late 1800s, the goal of treatment was directed at pain management and comfort care not cure. Until that time, most patient care occurred at home. Hospitals, which had developed as extensions of monasteries or as almhouses for the poor, the indigent and the sick, were often the place of last resort.

Before the stethoscope came into use by physicians in 1816, the doctor had no assistive technologies. In the absence of the many familiar devices today, a physician’s senses, especially looking, listening, smelling, touching and sometimes tasting, were critical. In the absence of technologies to evaluate the interior of the body, the patients’ story and physical appearance provided the foundational data to diagnose the disease and develop a plan of care.

The knowledge and skills for clinical diagnosis have always been complex. What changed in medical education and medical practice beginning in the 20th century was the unprecedented rise of new scientific knowledge and technologies and the evolution of hospitals as complex systems of care. The goals of care expanded from comfort to cure. These changes were both remarkable and disruptive to the practice and the institutional culture of medicine. By the 1960s and 1970s the benefits of scientific knowledge and technology were considerable, and not without consequences for the patients and for physicians who provided care. Physicians and their students spent less time at the bedside with the patient; the decline of bedside teaching compromised skills that were clinical and also relational.2

Clinicians and educators were concerned about the erosion of the “art” of medicine based on close attending and human relationships developed at the patient’s bedside. Other effects were also identified: “overspecialization, insensitivity to personal and socio-cultural values, over-medicalization of everyday life, too much curing and not enough caring, overwork of house staff” in the “bureaucracies that constitute modern medicine.”3 Medical culture was changing, and medical educators made efforts to to address this problem. 4

This transformation of medical culture and practices reflected a gulf between science and technology, and values.5 To bridge this gulf, humanities scholars, theologians, and medical educators proposed the introduction of humanities and visual arts into medical education in 1968. The field of medical humanities was created to attend to the human contexts of healthcare. Humanities and arts “offered physicians, medical scientists and other health professionals an opportunity to reflect on their own professions and to see their undertakings in the broader context of human concerns and aspirations.” By 1979, half of the medical schools in the US had developed courses, programs or departments of Medical Humanities.

To address the “dehumanizing effects” in the “bureaucracies that constitute modern medicine,”6 new curricula purposefully sought to understand the human contexts of values, beliefs and feelings of the patient as person. In addition, the curriculum focused on the student’s own personal and professional development to build skills of self-awareness about values, beliefs, biases and assumptions, and the humanistic and ethical care of the sick. In the 1980s, the American Association of Medical Colleges (AAMC) in its report, General Professional Education of Physicians (GPEP), made recommendations for major changes; one of them was the formal inclusion of humanities and implicitly visual arts, as well as humanistic social sciences in the medical curriculum.7

With the increase of scientific knowledge and a superabundance of information available on the Internet, the medical curriculum struggled to accommodate the required knowledge. The traditional medical school curriculum, comprised of two years of book-learning, much of it based on rote memorization was followed by two years in hospital settings with patients to apply book learning to the patient at the bedside.8

In 1998, the National Association of Medical Colleges issued its educational guidelines for a curriculum that better reflected the goals and objectives in student learning for the 21st century.9 In that year, the University of Rochester’s curriculum was re-configured to integrate the two strands of classroom learning and experiences with patients into a Double Helix curriculum, beginning in the first year. The teaching model integrated required rote learning and lectures with team learning in small groups around a medical “case” or “problem.” This Problem Based Learning (PBL) model engages students in learning as a problem-solving process, involving critical thinking and team work. The approach is student-centered and discussion-based; instead of a traditional lecture where students are passive learners, the group is facilitated by a tutor who serves more as a guide than an expert.10

In starting the conversation with an art museum educator to address an educational problem in the training of physicians, I was asking for a collaborator whose arts-based pedagogy might offer a new approach to understanding and teaching the clinical diagnostic process, given the curricular changes at our institution and in medical education in the 21st C. Was there more to be learned from the educational approach of museum education than the evident improvement in observational skills noticed in the Yale study?

1. Dolev, J., Friedlaender, L., & Braverman, I. (2001). Use of fine art to enhance visual diagnostic skills. JAMA, 286(9), 1020–1.
2. LaCombe, M.A. (1997) On bedside teaching. Ann Intern Med. 126, 217–20 doi: 10.7326/0003-4819-127-2-199707150-00047; Linfors, E.W. and Neelon, F.A (1980). “The Case for Bedside Rounds,” NEJM, 303 1230-1233 doi: 10.1056/NEJM198011203032110; Engel, G.L. (1971). “The Implications of Changes in Medical Education,” Hospital Practice, 6(12) 109-16; Engel, G.L. (1972). “Must We Precipitate a Crisis in Medical Education to Solve the Crisis in Health Care?” Annals of Internal Medicine 76(3) 487-490.
3. Self, D.J. (Ed.). (1978). The Role of the Humanities in Medical Education. Norfolk, VA: Bio-Medical Ethics Program, Eastern Virginia Medical School, 1-7. Based on a presentation given at the dedication of Upjohn’s new Research & Development Ctr in Kalamazoo, MI in Oct 76.
4. Engel, G.L. (1977 Apr 8). “The Need for a New Medical Model: The Challenge for Biomedicine.” Science, 196(4286) 129-36 doi: 10.1126/science.847460
5. Engelhardt, Jr., H. T. (1990). “The Rebirth of the Medical Humanities and the Rebirth of the Philosophy of Medicine: The Vision of Edmund D. Pellegrino.” Journal of Medicine and Philosophy, 15:237-241.
6. Engelhardt, Jr., H. T. (1990). “The Rebirth of the Medical Humanities and the Rebirth of the Philosophy of Medicine: The Vision of Edmund D. Pellegrino.” Journal of Medicine and Philosophy, 15, p 238.
7. Physicians in the Twenty-First Century. The GPEP Report: Report of the Panel on the General Professional Education of the Physician and College Preparation for Medicine. Association of American Medical Colleges, ED252102
8. Muller, S. et al. (November 1984). “Physicians for the Twenty-First Century: Report of the Project Panel on the General Professional Education of the Physician and College Preparation for Medicine”. J. Med. Educ. 59, Part 2
9. Anderson, M.B. (1998). Report I Learning Objectives for Medical Student Education-Guidelines for Medical Schools, American Association of Medical Colleges
10. Barrows, H.S. and Tamblyn, R.M. (1980). Problem-Based Learning: An Approach to Medical Education, Springer