• medical education
• medical school

British medical students enter medical school at the age of 18 and qualify 5 or 6 years later at the age of about 24. By that time they have spent their whole adult life—and, indeed, a quarter of their entire life—in one educational establishment. So all-encompassing, so involving, so potentially overwhelming is a medical school that sociologists such as Erving Goffman might classify them with other “total institutions” such as prisons, asylums, monasteries, and barracks where daily life is regimented, where the social world primarily revolves around the institution and its members, and whose ultimate goal is a plan structured as much for the ultimate benefit of society as for the needs of the inmates.

If educational environments really matter, then medical schools should be the ideal place for spotting an effect. So what demonstrable effect is there? Five years at 300 working days a year, eight hours a day (and never mind the nights), is more than the notional 10 000 hours which are said to be necessary to become an expert in a skill. Indeed, there are 2000 hours left over to become pretty skilled in a host of other activities such as playing rugby, drama, music, or any other avocation.

Anecdotes abound about the experience of medical school, and a useful anthology is “My medical school” edited by the doctor-poet Dannie Abse.¹ In his introduction, Abse comments on how many aspects of medical education seem common to all medical schools, and that there are more similarities than differences. An educationalist, however, reads the accounts very differently. When Lord Platt described how in Sheffield during the First World War there were only 12 students in the year, one wonders how the experience must have differed from that of Sir Derrick Dunlop in 1920s Edinburgh where “the crowd was so great that it was often necessary to stand on a bench to catch a glimpse of the patient under discussion”. Another doctor-poet, Edward Lowbury, contrasts 1930s Oxford where the emphasis was on “the growing points and gaps in knowledge, the disciplines of research and the critical reading of original papers” with The London Hospital where “the approach was more dogmatic, and the unwary might have imagined that all knowledge was wrapped up in their textbooks and lecture notes”. Is it possible that so many formative years in such different institutions resulted in doctors who are almost indistinguishable?

Despite its importance and obviousness, few studies have assessed the key question of the extent to which different educational environments—be they differences in philosophy, method of delivery, content, approach, attitudes, or social context—produce different sorts of doctor. Folk mythology certainly believes that medical schools make a difference—as the generic version of one joke goes: “You can tell a St Swithin’s man but you cannot tell him much”. However, an extreme contrarian view says that none of these things matter. After all, “cream rises to the top” irrespective of its container, and bright motivated creative medical students will pick out what matters from the multifarious raw material presented by their medical school. When multitalented ability is allied with a professionally driven motivation and a wealth of clinical experience (and, as Abse says, “Every patient ... teaches his physician about the subject of medicine”), then caring, compassion, and clinical competence are surely inevitable, whatever the educational environment. Hard data to refute that strong position are difficult to find, mainly because few studies have compared the educational effects of medical schools. There are many reasons for this, not the least of which is that institutions do not like being compared. When medical schools are weighed in the balance then some may be found wanting, so a sophisticated, self-congratulatory, mutually supporting culture of educational protectionism has arisen. Woe betide this person who asks such questions—they can only make enemies and few will thank them, even should the institutions themselves have originated the study.

Such an educational context, along with the intrinsic interest of understanding malpractice, makes the paper by Waters et al² in this issue of QSHC of double interest. Information on malpractice claims of individual doctors is publicly available in some American states, making it possible—without the need for schools themselves to cooperate—to ask whether the graduates of some schools are more likely to be sued than others. Of course, whenever institutions can be ranked in order then some are inevitably higher than others—after all, even random numbers differ in size—and the challenge is to demonstrate convincingly that such differences are genuine. Perhaps most crucial, as here, is the demonstration of long term stability; schools producing a higher proportion of graduates with malpractice claims at one time tend to be those that also have a higher proportion at another time. What might cause such systematic differences in the graduates of different institutions?

Many things, is the simple answer. Different sorts of applicant apply to different sorts of schools for different reasons,³ and different schools probably use different criteria and methods for selecting their entrants from among those applicants.^4,5 Medical schools differ in their social worlds and in their philosophy, outlook and approach to teaching,⁶ and students at different schools have different amounts of clinical experience.⁷ The net result of these and other differences is that graduates of different medical schools end up in different careers.⁸

“. . . the medical student is the aggregate of a range of influences . . .”

Implicit in any such view of medical education is an “additive model” whereby the medical student is the aggregate of a range of influences that model him or her in the way that clay is moulded by the fingers of a sculptor. That, though, is only part of the story. Medical schools are dynamic social institutions in which the students interact with each other, each year or class developing its own personality which is far from predictable from the sum of its parts. This becomes painfully apparent to medical school examiners who find a far higher proportion of failures in one year than previously, despite the course being the same, the examination being similar, and the average social and educational qualifications of the students seeming to be equivalent. Some years are “good” and others “bad” because students, like peers in general, influence each other in their attitudes and approaches to education. A more subtle version of this argument suggests that graduates of different institutions differ in relation to the diversity (the variance) in the individuals in their classes. A rich and complex social, ethnic, and class mix among the students is said, with some supporting evidence,⁹ to result in more socially able graduates who can interact more effectively in complex, modern social worlds.¹⁰

Whether any or all of these factors are responsible for the differences in malpractice found by Waters et al² is far from clear at present. What is clear is that graduates from different medical schools not only differ in their propensity to cheer for Light Blue rather than Dark Blue or some other colour, but also in their professional competence (or, more precisely, their incompetence). Understanding the reasons for this will tell us both about malpractice and about the enduring effects of different approaches to education.