Hilliard (‘Hill’) Jason | Radical Thinker in Medical Education

Hilliard Jason: They had promised to help us become humanistic, scientifically sound clinicians. Instead, we were sitting in large lecture halls being lectured at by people who didn’t understand how people learn or tune into what we were interested in or wanted.  It was mind-numbing and mind-boggling. I had the wonderful good luck of being at the only medical school in the world at that time, the University of Buffalo, in New York, that had a small group of faculty members who were also concerned about medical education’s direction.

            One young faculty member was working on getting a grant to develop the first ‘faculty development’ programme in a medical school. He invited me to consider something that he hadn’t planned on, which was to have a student participant, to include a student’s perspective. So, I decided that the really dull, uninteresting, intellectually stultifying experience of medical school could be transformed for me by this opportunity to work with some people who were actually thinking, who wanted to explore ideas, and learn what other people are learning about education. I said “absolutely”. I agreed to take some time off, by going to medical school half time, which our Dean agreed to my doing, which was amazing. I ended up pursuing both medical and education doctorates at the same time and that led to my career at the boundary between medicine and education.

            I was persuaded by advisors that I must pursue a specialty. The most relevant specialty seemed to be psychiatry, so I went on to a residency in that field. As it happened, an additional complication set in. I was a Canadian who had come to medical school in the US from Montreal. However, a disturbed, possibly psychotic, immigration officer decided I was a threat to the country. He arranged to have me kicked me out of the United States halfway through my residency. Happily, some senior people at McGill took me in and I finished my residency and a Fellowship at McGill in Montreal. I was then invited to come back to the United States and joined the faculty at the University of Rochester.

DMacA: When we look back, and that was quite some time ago, you must have faced considerable opposition with these radical new ideas in education.

HJ: Well, that’s putting it mildly. There were some very senior people at a national level who I had a chance to interact with, who observed that it was kind of courageous and possibly admirable for me to be pursuing a Doctorate in Education with my medical degree, but I was told over and over again: you understand that in medicine an education degree will be no credential at all. Nobody in medicine cares enough about education to acknowledge that such a degree is of any value. Several added that they don’t understand why I was wasting my time on such a pursuit. Well, as it happens, within less than 10 years, which isn’t much time in the history of medicine, I was asked by the Federal Government to develop an educational fellowship program for people in medicine who wanted to learn more about education. The landscape had started to change, not just thanks to me, of course, but thanks to several of us who recognised and were advocating for what was needed. Three of us who were asked to start those Fellowship programs. To my surprise and delight, in the very first year we had an application from a retiring Dean of Medicine, from a retiring Chairman of Paediatrics, and from several other senior people. There clearly was a beginning, bubbling awareness that we just weren’t doing enough to learn from the good research being done in education, and apply it in the medical education setting.

            In general, the medical setting turned out to be quite resistant to change, and still is. There are wonderful exceptions to that generalization, and there is now good research being done in medical education by leaders in the field. There are changes being made in quite a few medical schools. Unfortunately, people with whom I’m in touch, internationally, tell me there are still a good many medical schools that put hundreds of people in one room at one time and talk at them, hour after hour after hour, as if that’s supposed to be a form of education. That approach is not merely neutral, it’s negative. It leaves too many learners believing that if they memorize the assigned facts they will have done what is needed. That getting through the exams is a sign of success. They conclude that succeeding at this learning in school is enough. Far too many of them then make the decision to narrow their specialization down as much as possible so as to avoid being “stuck” with having to deal with the uncertainty and discomfort for facing unknowns.

            A hallmark of good Primary Care, of good Family Medicine, is a capacity for dealing comfortably and effectively with unknowns, dealing with the unpredictable. Sub-specialty practitioners tend to deal mostly with filtered patients, patients who have already been diagnosed by somebody else and who have been referred to the sub-specialists. They show up with a pre-assigned label.  If you are a doctor who is not open to ambiguity and uncertainty, you can be glad to accept those labels. There’s evidence that some sub-specialists just do what their specialty offers rather than what the patient demonstrably needs. Learning to be a doctor who can deal reasonably comfortably with ambiguity and uncertainty is not trivial. It takes role models who do that. It takes practice. It takes an environment that encourages humility, caution and investigation. And none of those things are prominent or even present in some educational programs, even though we’ve known about and understood this need for decades.

DMacA: I can see very clearly the type of outcome we want and the type of graduate we want but how do we actually do that, how do we change education so we produce that type of doctor, who is able to tolerate uncertainty?

HJ: The straightforward answer is: not easily. It takes specially prepared educators, not just doctors who happen to have a reliable pulse and respiratory rate and little or no understanding of the learning process. We need people who are genuinely well prepared, who have thought about these issues, who have explored them, who have gone through practice sessions, who have engaged in simulations where one deals with students who are uncertain.  We know how to do all these things reasonably well, but it takes time, it takes supervision, and it requires the effective use of well-designed simulations.  Many educational programs outside of medicine that deal with difficult, complex learning use simulation. A growing proportion of medical education programs have been using some forms of simulation, but not nearly enough yet. Simulation is where you can create artificially simplified experiences to begin practicing complex skills safely. You then gradually add more complexity, helping learners refine and expand their capabilities when they are ready. Educators need to go through such experiences themselves, to help them understand what their students need.

DMacA: It looks like we have an enormous challenge because there’s a pressure on medical schools to put through more and more medical students, classes of maybe 100 or 150 students and, at the same time, education isn’t valued. Biological and clinical research are  valued so much that educators have become, dare I say, almost second-class citizens in universities. How do we overcome this?

HJ: There are still medical schools in the world that don’t have just hundreds in a class, they have a thousand or two thousand, at least in their initial classes. It’s just bizarre. Talk about the blind leading the blind, these “educators” are people who don’t understand much or anything about education, and too many don’t want to. Meaningful change has to come both from the top and the bottom. There must be students and young faculty clamouring for change. But we need people at the top who are supportive and encouraging, certainly not resistant to refining their educational programs. People at the top can squelch any initiative they want to because they are dealing with young people who desperately want credentials. Until there are pressures and expectations from regulators and others, change happens very slowly.

DMacA: One of the other influences is the pressure to broaden the base of our medical student population so, when we talk about broadening the base of the medical student intake, do you think we’re choosing the right medical students?

HJ: That’s a hugely important topic. Our capacities as educators are quite limited. We are insufficiently capable of modifying personalities, deeply held attitudes, or highly valued traditions. The reliable way to get the product we want at the end of the educational process is to choose candidates at the beginning who are as close to what we want at the end as possible. We need a much more sensitive and carefully planned selection process than we typically have. We need to be looking for and selecting students who can tolerate ambiguity and uncertainty. We need to be selecting learners who have a capacity for deep connections with other human beings. These skills and characteristics are at the foundation of earning patients’ trust.  Without their trust we don’t get many of our patients’ whole stories. We’ve understood this for a long time. Many patients tell doctors what they think the doctor wants to hear, even what the doctor might admire rather than criticize. Patients must trust their doctor. They must be willing to reveal what is troubling them most, what are really their central concerns. We need to select student very carefully. How do we typically conduct our selections now? In many programmes we look mainly at how well candidates have performed on fact-based exams. These are often exams focused on the outcomes of science, not on the processes of conducting science, not the ways of discovering reliable information or on critiquing unfounded assertions. Being effective at memorizing what other people have claimed is not a foundation for a life of being an appropriately sceptical consumer and creator of new ideas and findings. We need the very best ways of choosing our future doctors.

DMacA: As an educational radical for a lifetime, are you optimistic for the future?

HJ: I have a lot of reasons to be cautiously optimistic now. There are people doing really good work in medical education research and practice. When I was starting out there was, nearly no journal devoted to Medical Education. There was one journal, published by the Association of American Medical Colleges in the US. It had a journal called the Journal of Medical Education, but it mostly published opinion pieces. It published very little research on medical education. Then, gradually, there emerged a source of surprise and encouragement, a source of optimism. Now, there are not only many journals devoted to medical education research around the world, even medical specialty journals, journals for surgeons, internists, gynaecologists, and other clinicians, are publishing research on medical education in their specialty practice journals. So, the world has, in fact, changed in the seven decades of my professional lifetime. In the history of medicine that’s a relatively short time. That leaves me cautiously optimistic.

DMacA: What a super note to end on.  With all the challenges, to end on a positive and optimistic note.  You’ve done an immense amount for medical education, I’m sorry we were only able to touch very briefly on the surface.  Thank you very much indeed.