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February 2, 2023+Richard Gunderman

Fostering True Diversity for Excellence in Medicine

Many educators see ourselves as strong advocates for diversity, yet in truth we are terrified of it. At one level, we promote efforts to open up the classroom to students from different racial, ethnic, linguistic, religious, and economic groups and varied sexual orientations and gender identities, yet all the while many of us are funneling them into an ever tighter and more regimented conduit. Instead of helping them become more open and curious about points of view that differ from their own, they often emerge more close-minded and intolerant. Consider medical education, a field in which I have labored for over three decades. Typically, accepted students are academic top performers, many of whom have also accumulated extensive experience in research, leadership, and service, often in other cultures. Nearly all are drawn to a career in medicine by a sincere desire to help others in need. They are, in short, as well prepared as any 22-year-olds could be to contribute to their communities and society not only as wage earners and taxpayers but also as citizens, neighbors, and human beings. Yet for many, medical school feels less like a progressive expansion and enrichment of intellectual horizons and more like passing from station to station along an assembly line. At most schools, students take the same courses, or at least cover the same material. The techniques of instruction tend to be very similar — lectures, small-group discussions, online learning modules, and a great deal of independent study. And nowhere are the forces of homogenization stronger than in evaluation, where students across the country typically take exactly the same multiple-choice exams. On one hand, a high degree of overlap in medical education makes perfect sense. There are core concepts and skills that every physician needs. Yet homogenization has its limits. Students matriculate in medical school with a wide range of interests and talents, matched by the diversity of their academic and cultural backgrounds and life experiences. Running counter to our enthusiasm for a diverse student body is the net effect of four years of medical school, which resembles funneling and assimilating more than the enrichment of cognitive, emotional, and spiritual perspectives. Consider creativity. Do medical students, on average, become more or less creative people over the course of four years of medical education? Students find themselves in a culture where knowing the right answer — or at least what the test question writer or professor assumes is the right answer — counts far more than the ability to ask probing questions, formulate and test a range of hypotheses, or play a role in advancing biomedical knowledge. They quickly learn to presume that there is one correct answer, and they better know it if they want to succeed. This outlook is absolutely antithetical to what we might call an inquisitive mindset, and many medical students experience a profound culture shock in their first year. Students with engineering backgrounds, who have spent their academic careers solving problems, are astonished by the amount of information they are expected to commit to memory. Students with backgrounds in the humanities, who are accustomed to being evaluated according to the quality of arguments they construct, are flabbergasted to discover that they must choose the one best response. We are paying an immense price for an educational system that more closely resembles indoctrination than adventure. Despite the expenditure of ever-increasing amounts of money, the curve of biomedical innovation has been flattening over the last few decades, due in part to the fact that most of the nation’s nearly one million physicians have passed through an educational system that prizes knowing right answers over asking good questions, preferring a culture of cognitive conformity to skepticism, curiosity, and risk-taking. In a thriving society, the members of professions such as clergy, law, teaching, and medicine would be the bellwethers of freedom of inquiry, belief, and expression. Their schools would be bastions of lively discussion and debate, not only open to but encouraging the exploration of multiple different points of view and vigorously testing them out in conversation and practice. But in many cases, such institutions are anything but, and one fundamental problem is a lack of awareness, understanding, and experience with lively intellectual discourse. No one experiences an epiphany memorizing the content on note cards or selecting the one best response to a multiple-choice question. Such moments of recognition and communion cannot be controlled in the same way a medical student can be told to read a chapter in a textbook or spend some number of hours reviewing notes. We can help establish optimal conditions — removing distractions, really centering ourselves, and trying to be as fully present as possible — but whether something in the way of meaningful discovery actually takes place is largely out of our hands. Despite numerous efforts to reduce the practice of medicine to computer programs and artificial intelligence, doctoring well remains a distinctively human activity that requires curiosity, insight, creativity, and compassion. A good physician needs to be able to hear what the patient is saying, grasp the many nonverbal aspects of communication, and infer what the patient is trying to say. Excellence in medicine means asking great questions, thinking creatively, formulating and reformulating hypotheses, and genuinely caring for other human beings. Real diversity has less to do with the color of students’ skins, their native languages, or their gender identities than the degree to which they fully realize their distinctive potential to know and care for other human beings. Virtually all of them are more than bright enough to garner the necessary knowledge and skills. What really matters is the degree to which they develop into the best possible version of themselves as both physicians and human beings and, ultimately, the capacity of future physicians to adapt their approach to each unique patient for whom they will care. To make the most of diversity among medical students, changes are needed. These might include moving away from multiple-choice evaluations to essays and oral exams, founding book clubs and debating societies to engage students in intellectual discourse beyond the conventional medical curriculum, encouraging more medical students to undertake scholarly and creative projects that develop their distinctive interests and abilities, and developing opportunities for more medical students to become engaged in service and leadership in universities, hospitals, and communities. Preparing to be a physician should provide one of the best liberal educations available at the graduate level. By exploring and experiencing health and disease, injury and healing, and life and death firsthand, both in medical school and throughout long careers in the profession, physicians should become better neighbors, better citizens, and better human beings. The time has come, or is perhaps long past, for us to reinvigorate such a vision of excellence in medicine, which should serve more broadly as a model of excellence in higher education.

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