Apr 27, 2011 - fit on Western medical practice. My subsequent reading of Druin ... iture at the University of Melbourne was exceeding income, the answer was ...
Q 2011 by The International Union of Biochemistry and Molecular Biology
BIOCHEMISTRY AND MOLECULAR BIOLOGY EDUCATION Vol. 39, No. 4, pp. 326–327, 2011
Multimedia in Biochemistry and Molecular Biology Education Commentary: Bad Medicine and Bad Educational Practice Received for publication, April 27, 2011 Graham R. Parslow‡ From the Department of Biochemistry and Molecular Biology, The University of Melbourne, Victoria 3010, Australia
As a teacher of medical students, I have taken a keen interest in the history of the teaching and practice of medicine. The definitive treatment of medical history by Porter [1] left me in no doubt that it is only for approximately the last century that science has imposed a balance of benefit on Western medical practice. My subsequent reading of Druin Burch’s Taking the Medicine [2] inclines me to believe that it is only the last 30 years that can be regarded as the era of evidence-based medicine. Dr. Benjamin Spock thought there was no evidence that spanking created more disciplined children who would become responsible adults. With equally little evidence, but with faith in his experience as a Freudian pediatric psychiatrist, he advocated benign tolerance of temper tantrums and allowing children’s self-indulgent behavior. Spock’s Common Sense Book of Baby and Child Care [3] became the best-selling nonfiction book of all time and had a dramatic effect on child rearing practice in the 1950s and beyond. The changes may have done more harm than good, but in one particular we can be completely sure that Spock was in error. Spock advocated that infants should not be placed on their back when sleeping, to avoid choking. This advice became standard practice through to the 1990s when scientific studies revealed significantly increased risk of sudden infant death syndrome associated with putting babies stomach-down. It has been estimated that as many as 50,000 infant deaths in Europe, Australia, and the US could have been prevented had this advice been altered when the evidence became available [4]. Burch [2] provided a similar picture of medical ineptitude when cardiologists failed to adopt useful aspirin and streptokinase treatments, and they embraced harmful arrhythmia treatments sponsored by big-pharmacology. Intuitive medical theories that give a basis to practice, such as Freudian psychology, have systematically been falling apart in the face of objective data. I have been a problem based learning (PBL) tutor for a decade and because of the intense effort required, we
‡ To whom correspondence should be addressed. Tel.: 61-383445925; Fax: 61-3-93477730. E-mail: gparslow@unimelb. edu.au. DOI 10.1002/bmb.20528
like to believe it is a better way of teaching. Kaufman and coworkers [5] performed one of the rare objective tests on the efficacy of Problem Based Learning at the University of New Mexico starting in 1982. By good fortune, it was a time that the US government was making grants to perform expensive trials in educational methodology. It was possible to do a 50% split on the medical intake at New Mexico and put one-half through the established lecture course and the other half through an innovative problem-based learning course. The hope was that the problem-based cohort would out-achieve by striving to understand the rationale for diagnoses and treatments while the other half ‘‘were trying to memorize the names of all the holes in the skull’’ [5]. It turned out that the optimism and prejudices of the PBL sponsors were entirely repudiated when the data were analyzed. Problem-based learning was not demonstrably any better than conventional medical teaching and conventional teaching was superior in achieving comprehensive coverage. This was not the end of PBL as a method, because it remained one of the few credible alternatives that innovative course designers could incorporate. After contracting an accountant to find out why our medical teaching expenditure at the University of Melbourne was exceeding income, the answer was almost entirely the hidden cost of running PBL. The cost of paying tutors was relatively minor, but there were enormous costs for full-time support staff and servicing of the tutorial rooms. This additionally illustrates the human fallibility of believing that something that is expensive must be good, a common error in medical practice. Objectively the ‘‘feel good’’ aspect of PBL cannot stand against the ruinous expense. For expensive medical treatments the cost benefit analysis now needs to have a statistically sound affirmation of benefit, but this lesson has not flowed to education. We live in an Orwellian age, where our politicians strive much harder to get the right spin on their actions than they strive to formulate good policy. Publicity (preferably positive) drives many activities in contemporary society. We do not encounter a headline such as Sound Teaching practices proven at local University, but we can read of hopeful approaches for using new technology. An article in my local newspaper [6] described how the world’s
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327 largest purchase of iPads for teaching will lead to better teaching and understanding. More cynically, I suspect that it will lead to the world’s largest pile of obsolete iPads in 3 years time [7], and may have done more educational harm than good as well meaning lecturers fumble about to get some value out of all of those iPads. In medicine, patient survival after treatment is an objective measure that cannot be manipulated. However, in education, we normalize the distribution of our marks to get a profile that is largely invariant between years. This gives us little ground for evaluating the true efficacy of educational approaches. It is now time for educators to learn the lessons of medical accountability, and Laura Furge has foreshadowed how Institutional Review Boards may increasingly impose accountability for education initiatives to bring education into an evidence-based era [8].
REFERENCES [1] R. Porter (1997) The Greatest Benefit to Mankind, Harper Collins, London. [2] D. Burch (2010) Taking the Medicine, Vintage Books, London. [3] B. Spock (1st ed.1946, 8th ed. 2004) The Common Sense Book of Baby and Child Care, Duell, Sloan and Pearce, NY. [4] N. Swann (2006) Facing the Evidence. www.abc.net.au/rn/health report/stories/2006/1735075.htm (accessed April 8, 2011). [5] A. Kaufman, Ed. (1985) Implementing Problem-Based Medical Education, Springer, NY. [6] G. Maslen (2011) Tablets Emerge as New Uni Tool. Melbourne Age. March 8, p. 14. Online at www.theage.com.au/digital-life/tablets/ tablets-emerge-as-new-uni-tool-20110307-1bl03.html (accessed April 11, 2011). [7] A. Moses (2011) Tablets might be a flash in the pan: Microsoft global chief strategy officer. www.theage.com.au/digital-life/tablets/tabletsmight-be-a-flash-in-the-pan-microsoft-global-chief-strategy-officer20110330-1cfv2.html (accessed April 11, 2011). [8] L. Furge (2011) Institutional review boards and educational research, Biochem. Mol. Biol. Educ. 39, 85–86.
