In my last contribution to CDTL’s publications five years ago (Oh, 2000), I made two points which I will revisit in the present paper. I would first like to re-examine the statement that: “the smarter scientists understood the limitations of both the empirical method and available technology. Karl Popper has shown that experiments can only disprove hypotheses; in proving concepts, an element of uncertainty remains forever. Instead of being paralysed by uncertainty, however, students can and should derive a zest for research from it”.

From my observations of students in the School of Medicine for over 25 years, I believe that many are still unable to adapt their school-derived attitudes towards knowledge, and consequently fail—to an extent—to accept learning and research as an endless exploration, or an evolving adventure. Instead, they become increasingly discouraged by the lack of certitude in many areas of medical science and, worse, the continuously evolving methods of diagnosis, investigation and of patient treatment. It is similarly unsettling for practising physicians to note often that the ‘best treatment’ of today becomes the obsolete or even harmful ‘misguided practice’ of yesterday.

Faced with the shifting ground of medical knowledge, a few unfortunate students may be so fatigued or, worse, bored by the business of learning that they retreat to their default mode. By this, I mean the minimalist method of only learning just enough, and just in time, to pass the continuous assessments. In Medicine, this often means learning only the transient practice guidelines that students may acquire during hospital internship, or (more likely) Web-based extracts of dubious accuracy and currency. Whereas minimalist learning may enable students to pass examinations and survive the rigours of practice for a time, it is clearly insufficient for practising medicine as a lifelong career. Students locked into this mode tend to be poorly motivated, unquestioning and perhaps depressed. Later, they may be professionally uncritical. In short, the behaviour is a prescription for probable under-achievement or, later, a possible disaster (e.g. serious injury or death of a patient).

In the past five years, I have not observed any significant change in the number of students who own up to minimalist learning. Does this mean that the curricular changes have not produced any detectable benefits? The answer is no as there may be many factors affecting this trend. Firstly, there should be a systematic follow-up study of the behaviour. Secondly, it is difficult to measure the influence of curriculum change on learning across student cohorts. Thirdly, the methods of performance assessment have changed in the same period, so that any benefits might fall below the detection threshold. Lastly, five years might be too short for any changes to take place.

The second statement I would like to re-examine is: “we learn far more from being wrong than being ‘correct’. Infants, if not unreasonably inhibited, discover their surroundings by exploration. Through error they learn their own limits of action. So should all students”.

Many students are consistently reluctant to admit either ignorance or error. I believe this results from a sudden erosion of the confidence built upon success in school-level physics, mathematics and chemistry—all subjects in which high scores result from knowing principles, laws and formulas. By contrast, biology—the science of living things—is so complex and strongly weighted towards the steady-state that most changes are small. Some biological laws (e.g. Darwinian evolution) are so counterintuitive (or require such leaps of imagination) that many people reject them completely. By extension, Medicine—a subject that encompasses both human biology and pathology—is enormously complex, and individual treatment outcomes in clinical medicine are unpredictable for some, and less than dramatic for many people. Add the behavioural quirks of patients to this combination and it should surprise nobody that some students cannot cope with caring for patients and thus lack self-confidence.

It does not help that we live in a multicultural and polyglot society. Older people are separated from younger ones not just by gaps of experience, attitude or style, but also by differences in language: many patients over 60 years old speak only dialects. The older patients view disease and sickness differently from the younger students, who may uncritically accept the deep medicalisation of life’s down-times that dominates mature societies in the West. Medicalising your experiences means labelling every episode of disappointment ‘depression’ and calling women’s relative indifference to physical sensation ‘female sexual dysfunction’. Serious difficulty in communicating effectively with patients is an obstacle in many student encounters. The first step towards defining the patient’s problem is thus a stumble.

How do we limit the number of students overwhelmed by these challenges in learning Medicine? One effective way is to carefully select, upon entry into medical school, candidates who possess the following combination of attributes: great enthusiasm for learning, honesty, optimism, a willingness to accept fallibility (i.e. humility), outstanding communication skills and a personal concern for human welfare. Most candidates in this country have survived the rigours of school. But the stamina required to sustain long years of service to demanding patients is of a different order. Therefore, exceptional determination or ‘true grit’ is very important, as is a burning wish to make things better.

However, the Yong Loo Lin School of Medicine at the present Kent Ridge campus offers only an integrated five-year course, stacked with learning needs, and is somewhat unforgiving. Perhaps the upcoming graduate medical school at the Outram campus will allow some students, who are matched to its mission, to develop well. But, we must consider that such a graduate medical school, charged with producing both competent clinicians and high-performance bioscientists faces a very tall order.

In the last five years, I have been encouraged by more students asking sensible, and even probing, questions about the nature of Medicine and human biology. This may reflect a refreshing openness to discussion and exploration, or more vocal students, or (as many of us hope) both of these trends. However, there is still a reluctance to voice questions and to thrash out disagreements through argument. I regularly assure students that no question is too silly to ask, and that someone is usually happy that an apparently daft question has illuminated a topic.

In conclusion, I would like to emphasise that to be sufficiently self-reliant in dealing with hospital or clinic patients, students need to have met enough diverse people to be able to think straight and argue convincingly on their feet. Ideally, they should saturate themselves in this quest to experience unfamiliar patients and conditions. Since the quest can be tedious and unrewarding in the short term, students have to be self-driven, which leads me to conclude that, with medical students, it is mostly about ‘motivation, motivation, motivation’.

References

Oh, V.M.S. (2000). ‘Living and Learning Medicine: the First 30 Years’, in Pan, D. & Mohanan, K.P. (Eds.). Reflections on Teaching: the NUS Experience. Singapore: Centre for Development of Teaching and Learning, National University of Singapore, p. 58–59.