Critical Thinking in Medicine Died in 2020
And all of us are paying the price until that changes....
Healthcare Education Has Dramatically Failed Us
Two disparate but intimately linked events occurred in the past week that prompted this essay:
On August 17, 2022, the head of the CDC, Dr. Rochelle Wilensky uttered a tremendous understatement:
"In our big moment, our performance did not reliably meet expectations," Walensky said in a statement to the media.
"My goal is a new, public health action-oriented culture at CDC that emphasizes accountability, collaboration, communication, and timeliness," she wrote in the statement. "I want us all to do better and it starts with CDC leading the way."[1]
As many politicians do, she attempted to blame the problem on faulty messaging when the reality goes deeper…much deeper.
The second was an email message from a fellow physician and COVID-19 researcher, relating her own medical experience. She had recently gone in for a medical visit herself. The 4th Year Medical Student who interviewed her wore a tag with a prominent rainbow across the top, a small logo of her medical school and, prominently displayed where the name would normally be was the declaration of her pronouns. I guess her name was considered unimportant….
I realized we have come to a point in healthcare education, particularly medical education, where a drastic change will be needed if we are ever to regain the trust of society. I myself have spent 40 years in one form or another of academic medicine. I am a retired Professor and have functioned as a Director of Resident Education, Secretary of Education of an international subspecialty organization, two decades as the Research Advisor to a fellowship training program and served in multiple positions of medical leadership in local, national and international organizations. And I am profoundly discouraged at what I now see..
It is clear that we have failed in using the concepts of critical thinking, integrity, ethics, courage and moral reasoning in our admission criteria as well as in our evaluation for advancement in our profession. We have spent the last decades in relying on elements that we can objectively measure, such as Board Scores and class ranking and ignored what is actually important in the ethical delivery of care.
We have placed an emphasis on early introduction to STEM courses for those interested in the health professions.[2] Unfortunately, the development of Critical Thinking has been conspicuous in its invisibility.[3]
Of even greater concern is the lack of development of moral reasoning in medical students.[4] Part of the problem is the need to pack more and more information into the same finite period of time allowed for a medical education.
The problem is difficult, to be sure, but needs to be addressed sooner rather than later. Part of the challenge may be that this has been understood to be a merely complicated rather than truly complex problem.[5] COVID-19 has added as a searchlight, exposing the glaring deficiencies we have in the basic fabric of healthcare, not just in the United States but indeed worldwide. Agencies we have trusted to give correct and unbiased information have been shown to be critically flawed. Medical advice has been seemingly allowed to be diluted by political and ideological biases. We have come to the point where basic trust in not just governmental health agencies, but in medicine itself and individual physicians is at a dangerous low. I know, because my basic trust has been severely eroded…
So, what to do? Clearly, something must be done if we are ever to restore public confidence. We need a broad-based public discussion of this problem and cannot just allow those who have failed us so dramatically to just change the messaging but leave the underlying deficiencies untouched.
One thing seems certain: we must spend more time in understanding how the elements of critical thinking, integrity, ethics, courage and moral reasoning can be fostered early in the education of health professionals. It will never be enough to leave all of this to professional school. While STEM excellence is necessary for health care professionals, we can see it is definitely not sufficient. A visionary approach, utilizing at the very least undergraduate education and even secondary school will be needed to insure we will never again have such a catastrophic failure as we have had over the past two years. Imagine a graduated program over a period of 4-6 years prior to entry into professional school where students interested in medicine, dentistry, nursing, health policy and administration and even public planning can form a true vertically and horizontally integrated Community of Practice. Imagine this as a seminar series with minimal lecturing but maximum inspiration and mentorship, utilizing the experience of professionals in the individual geographic areas. Imagine this Community of Practice involved in actual Action Research on problems that are important to their local area.[6] Imagine a Capstone Project where students can take their experiences, capture their learning and translate that into demonstrable action. Then imagine all of this being made available to supplement evaluation for entry nto the health professions. Finally imagine these Communities of Practice being carried forward as these individuals advance in their healthcare professional lives. I see a tremendous potential!
It may be impossible to expect these changes will be initiated or even embraced by academic medicine, as it has been an integral part of the problem. More stakeholders need a voice. We may need something as far-reaching as the original Flexner Report. This is too important to leave to the very individuals who were incapable of rising to the challenges in the past.
[1] https://www.nbcnews.com/health/health-news/cdc-director-calls-drastic-changes-agency-rcna43536, accessed 8/18/2022
[2] https://www.nsta.org/resources/medical-schools-offer-stem-pipeline-programs, accessed 8/18/2022
[3] https://www.bmj.com/content/357/bmj.j2234 accessed 8/18/2022
[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4560952/, accessed 8/18/2022
[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6009054/, accessed 8/22,2022
[6]https://www.researchgate.net/publication/309361285_Action_research_healthcare_Focus_on_patients_improve_quality_drive_down_costs, accessed 8,22,2022