Medical students want syllabus 3.0

I've been getting feedback from students over the last two years on what materials they would like to have included in the course materials distributed with our second-year neuroscience course.  I have heard a very clear message from the students over the two years I've been teaching the course.  The expectations for what is included in the course materials and which readings are required has changed over the last few years.

Let me take you back to the mid-nineties when I took my medical school course work (and my college experience in the early 90's).  Let's call this syllabus 2.0.  I received copies of all the slides presented (as long as they were in PP, we still had some lecturers who used slide carousels and they had minimal notes printed - call that syllabus 1.0).  In class we took notes.  If you missed or ditched class, you could look back over what the lecturer talked about by subscribing to a note taking service which was run by the students.  Readings were from the required textbooks.  Test questions covered anything in the printed syllabus as well as anything said verbally in lecture (even seemingly off-hand remarks) and anything covered in the textbook.

In this model, the material is presented, but there is a intentional (or unintentional) fire hose level of information delivered.  It was up to the student to wrestle with this large volume of information, distill it down to essential concepts, and organize it in their brain to allow them to pass the test.  It was expected that there would be some test questions which were not covered explicitly in class, and the purpose of those questions was to differentiate the top of a group of very highly motivated students.  The upside of this model is that if forces the student to be able to analyze large volumes of information some of which is not a core concept, and independently synthesize the important concepts.  This skill is not outside of the required skill set to be a doctor in a clinic.  The downside is that there is room for the individual student to miss the boat and miss out on important concepts which aren't explicitly identified as core.  Also, this model can increase student anxiety during test preparation as you are not clear until you take an exam if you are missing the boat.

Let's move to 2013.  Our course syllabus was inherited from the above paradigm,  and we have been modifying multiple lectures.  Hence our lectures don't have well developed outlines or notes by the faculty to accompany PP presentations.  Students have on several occasions pointed me towards courses at our institution and others where the course materials include extensive annotation by the faculty in addition to the slides.  Students over the last two years have said things like (paraphrased):

"What I want is to have everything I need to know about this lecture written down so I can go learn it."
"I don't want to have links to a whole bunch of useful information about a topic, I want a single link to a very succinct, applicable resource."
"Even if the syllabus for a class is 450 pages, if it is all I need to look at, that's what I'd prefer."

Another way to state this is the students would like a curated information repository which is finite, organized, and focused on the learning objectives.  This sounds to me like it is mirroring discussions about moving from web 2.0 to web 3.0.  In other words, there is a desire to block out noise and focus on what is important to the individual.  Thus, all information in the course materials is honed to efficiently deliver information necessary to perform well in the course.

The upsides of this is that is very clear what the student is expected to learn.  From a pedagogy standpoint, this is an ideal situation for an educational model based on measuring competence.  Hence it is clear what measure to obtain, and all learners can potentially reach this bar.  The downside is that this perhaps does not help in the long run as this is not how real life medical decision making occurs.  There is no finite set of combinations of signs and symptoms, so often there is a need to be able to process a cacophony of noise and distill out the important ideas.  There is always more to read or more detail, and part of being a doctor is gaining skills in deciding how to be your own curator.

Which is better?  My view is we should aim in the grey of the middle.  I think it should be clear what is necessary to pass the exam, and if all material covered in class, small groups, and presentations is mastered.  I agree that if there is a picture slide, that it is reasonable for a lecturer to include some text to create context for the slide.  I do think it is also reasonable to have some way of assessing whether a student can surpass these minimal competency levels.  On an exam, that means asking questions which may not have come specifically from the readings.  It may introduce a novel topic and apply the concepts learned in class in a new way.  What are your thoughts on how much detail should course materials contain?

Clinical assessment variability - what is really causing it?

There was a recent article in Academic Medicine by Dr. Alexander and colleagues from Brigham and Women's Hospital describing the amount of variability in clerkship grading among US medical schools.  They found that, unsurprisingly, the grading systems for the clinical years had really no consistency at all.  There was inconsistency among the grading systems used (traditional ABCDF or honor/pass/fail or pass/fail) - (table 1), and even within the schools which used a similar scale the percentage of students receiving the highest grade was all over the place (table 2).  So, the question is what do we do with this information?  I think no one really expected findings that were different, but now the answer is out there, in print (or on digital reader screens).

I think part of the answer to where we go from here is to decide if this article was really asking the right question.  The authors do start to talk about this in the discussion section, but I'll try to lay out my thoughts with a little different spin than they gave their discussion.  I think the real question is what are we using the assessment of the clerkship performance for?  What is the essence of what we are trying to measure?  Only when there is broad consensus not only between schools, but within the individual courses of each school will there get to be any semblance of uniformity of grading of students.  I see at least two competing interest which influence how a clerkship director decides to come up with a grading system.  The first is the idea that the students should be measured on how competent they are in the area the clerkship is grading.  In other words, when they are on call as a first-year resident or as a 50 year-old physician, do they have the knowledge and skills to assess a patient with a given problem.  Second, the clerkship director also wants to be sure that the students at their school have a fair chance to compete for selective residency programs.  Thus, there also needs to be a system to distinguish high-achieving from low-achieving students.  The first system is more about the individual student, and with this system, by definition, everyone should be able to achieve the highest score with enough effort and work.  In the second system, it is more about evaluation of the program, and the group.  In this system, it cannot be possible for everyone to achieve the highest score.  However, the system can be manipulated on both sides to aid students or to make it more hazardous.  There are benefits and risks of each system - as with anything in medicine.

I don't think these interests are necessarily incompatible, but they create a tension which I've seen in national meetings and in local curricular meetings.  I also think most clerkship directors are not aware of how this tension affects the grading system they have developed.  I think their not aware as the debates I've heard are usually about tools for assessment or the numbers of honors.  Rarely does the debate get to the level of what is our ultimate purpose for the assessment.  The answer to that question must shape how grades are assessed.  Only when we all become very clear about what we our goals are for the assessment will we truly be able to come to a place where we can have a national dialogue about how to unify the system.