Beyond the Right Answer

Article Content

In the first year of medical school, experts estimate that medical students learn around 9,000 new words. Over four years of medical, that equals between 30,000 and 55,000 complex medical terms added to their knowledge base. Learning new terminology is just one aspect of the medical educational journey.

At the University of California San Diego School of Medicine, all students complete two years of Equity in Systems Science (ESS), a longitudinal course where students engage in small group, self-directed learning and explore topics such as health care delivery, teamwork across professions and quality improvement. The course is co-directed by Weena Joshi, MD, associate professor of pediatrics and Audra Meadows, MD, professor of obstetrics and gynecology.

“Unlike all of the other pre-clinical content that teaches students about what happens within the four walls of the exam room, the ESS course teaches students about what happens outside of the exam room,” said Joshi. “It’s important for the students to engage in self-directed learning because that is how they continue to learn after completing medical school. Through the course, the students learn skills like conflict resolution and teambuilding. They also gain an understanding of how health systems work. Those skills will be helpful and necessary down the road.”

For each class meeting, the students are presented with a case or scenario involving a patient. Working in groups, they determine what the next steps should be. Exercises in the course include everything from team building to understanding the complexities of value-based medicine. Scenarios are taken from real life examples including challenges that a third-year medical student might face in a clinical setting.

“For example, when we talk about conflict resolution in team building, we talk about the awareness of the emotions in the situation,” said Joshi. “How do those emotions influence potential conflicts? We practice strategies to regulate responses and identify behaviors that increase or decrease psychological safety for everyone. Then we critically evaluate what happened and how the students reacted to it.”

In one scenario discussed in the course, a medical student sees a stroke patient and gathers their medical history. The student then presents the patient’s medical history to the patient care team – first to a resident followed by the attending physician who has a direct teaching style that did not seem collaborative to the student. Over the next few shifts, the student attempts to find time to talk to the attending about what they could have done differently with the patient, but it never quite works out. The resident advises the student to stop bothering the attending, saying their persistence could affect the student’s evaluation. At the end of the rotation, the attending physician provides an evaluation stating that the student should have been more thorough in presenting their cases and more confident in their delivery of patient information. The student, who had tried to be more thorough, ends up feeling unsure of their history taking and presentation skills. When the student is asked to formally evaluate the attending, they provide average ratings with no open-ended feedback. The student then moves on to their next rotation, thinking that that the previous department and specialty is not the place for them.

“After sharing the scenario, the students are tasked with working together to create a structure for formal feedback that includes useful information from both sides,” said Joshi. “We ask them to create a pathway to provide support for both students and faculty to give and receive feedback, asking them to consider the perspective from each team member, the medical student, resident and attending.”

The goal of these types of scenarios and the team-based format is to encourage lifelong learning and critical thinking skills that the students will use as they progress from medical school to residents to practicing physicians. Learning to work together in a team and relying on input from others will help their future success.

“In this course, the students have to come engaged,” said Joshi. “We don’t provide an expert standing at the front of the room reciting information to them. We provide facilitators who help guide discussions, but they are not there to provide answers. The students have to work through it together.”

In another scenario, the medical students discuss a case in which an undocumented immigrant who feared seeking care, has significantly progressed in her illness. The students work together to determine how to engage collaboratively with the patient to improve her access to care, while ensuring that her other needs are met.  The students are asked hard questions about data ethics and the complexity of data use as it relates to patient care. “We ask students to think of the implications around using data in a data rich world. Many students use Epic, our electronic medical records system, for the first time during the case and are surprised at the level of access they have to sensitive information,” said Joshi.

The course challenges the students in a different way than most didactic courses. Joshi noted that there are no right or wrong answers with each scenario that is presented to the students.

“We remind the students that a big part of the course is encouraging them to reflect with humility after each session,” said Joshi. “It’s sometimes easier to focus solely on the pathology and treatment for the patients in front of them. But it’s much more difficult to understand the systems that affect their ability to treat patients, as well as the systems that affect patients’ outcomes.”

Joshi added that the course can be very difficult for students who have been trained to answer questions on exams with one correct answer.

“Multiple choice exams are very comforting,” she said. “To know there is one right answer is helpful. But in reality, the number of possible answers in these scenarios, and in life, is infinite. We need to make sure the students learn skills that stretch their thinking in many different ways to work towards building systems that have equitable outcomes.”

Over time, students begin to recognize that the real lesson is not about finding the “right” answer, but about learning how to pause, reflect and grow. The practice of asking for feedback, sitting with uncertainty and adapting to new knowledge are what prepare them to keep learning long after medical school ends.