Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of. Technology and Technion Sleep Laboratory, Israel. A survey by Rosen et al. (1) on physician ...
Sleep, 16(8):760-761
© 1993 American Sleep Disorders Association and Sleep Research Society
Short Notes Physician Education in Sleep Disorders-A Dean of Medicine's Viewpoint Peretz Lavie Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology and Technion Sleep Laboratory, Israel
A survey by Rosen et al. (1) on physician education in sleep and sleep disorders in the U.S.A. has revealed that there is an enormous gap between the establishment of sleep medicine as a legitimate branch ofmedicine and the incorporation of sleep medicine into the curriculum of medical schools. Rosen et al. bluntly concluded that sleep medicine instruction in U.S. medical schools is practically nonexistent. As a practicing sleep researcher, who has recently become a Dean of Medicine, I would like to share some of my views on matters related to changing the curriculum in medical schools and, in light of these, to offer some practical suggestions how to penetrate the curriculum walls of medical schools. There is a general agreement among medical educators that departmental territoriality and lack of centralized coordinated planning are stagnating contemporary medical education. Post-World War II medical education has turned into a "confederation of semiautonomous baronies. The barons (departmental chairmen) have been able to pass the dukes (deans) and the kings and queens (university presidents), to whom in principle they are beholden." (2). In most medical schools autonomous departments compete for the most square feet of laboratory space, the biggest grants and the brightest researchers. This spirit of competitiveness spills over into the education arena. In a recent study inspecting the strategies for introducing innovations into the medical curriculum (3), 50% of the administrators from 118 medical schools stated that leadership by the dean, associate dean for academic affairs or curriculum chairman was the most important element in promoting educational change. Faculty commitment was cited half as often. The im-
pediments to curricular changes were identified as faculty conservatism, departmental autonomy and lack of curricular committee authority. The nonexistence of sleep medicine in the medical curriculum reflects these difficulties in achieving any kind of change in the curriculum of medical schools, rather than a lack of appreciation or relevance of sleep research to medicine. Rosen et al.'s astonishment at the meager attention paid to education in sleep medicine reflects some naIvete concerning the considerations involved in accommodating medical school curriculum to any kind of new information. Such changes are slow to come and even when initiated may take several years to be completed. Most innovative changes in medical schools are enclaving and piecemealing. These involve procedural or sequential modifications in existing programs, which are implemented through political compromises among departments with vested interests. Overall, they have negligible impact on the curriculum as a whole. In retrospect, the 1988 American Professional Sleep Society (APSS) task force recommendations regarding medical school curriculum, which required the availability of a sleep disorders center within the clinical facilities of the medical school and the development of a new specific unit to coordinate and supervise the teaching in sleep medicine, fell into the trap of viewing innovative changes in the medical curriculum as a process guided by rational and logical considerations. These types of holistic changes advocated by the APSS, which might affect the infrastructure ofthe entire school, are the most difficult to get adopted, because they inevitably change the power balance within the school. How then can we proceed in order to secure the
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PHYSICIAN EDUCATION IN SLEEP DISORDERS proper place of sleep medicine in the medical school curriculum? In Hendricson et al.'s survey concerning changes in medical school curriculum (3), there was a consensus concerning only two areas where innovative changes must be implemented rapidly: ambulatory care training and the provision of interdisciplinary courses on emerging health care issues. Courses in sleep medicine definitely fall into the second category. As a first realistic goal for sleep researchers, I propose active campaigning among medical school curriculum committees to introduce an interdisciplinary course in sleep medicine. This could be offered as a 4th-year elective course, as was proposed by Rosen et al. Rather than focusing only on sleep pathology, however, such a course should encompass a wide range of subjects, ranging from basic sleep physiology to sleep disorders. Judging from past experiences, such a campaign may be much more effective if it is introduced by the identified agents of innovative changes: the dean, associate dean for academic affairs or the chair of the curriculum committee. They should be approached first and convinced of the importance of such a course. If met with resistance and objection, politically related or otherwise, it can be started as a limited or experimental trial and later on continued as an institutionwide effort. I can offer my experience in implementing such an approach. Since 1978, I have been teaching an interdisciplinary course in sleep medicine to 3rd-year med-
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ical students. (The medical school at Technion has a 6-year program.) This 14-week course, which is elective, has been attended by 80-90% of the students of each class. I am convinced that, regardless of who will be the next dean of medicine, this course will become a permanent part of the curriculum core courses in the foreseeable future. Lately, in response to students' demands, a follow-up course focusing on sleep disorders was added as an elective for 4th-and 5th-year medical students. This course, which has been attended by a smaller number of students (10-20 per year), allows evaluation of sleep-disordered patients, "hands-on" experience in the sleep laboratory and in-depth study of sleep pathology. Only after becoming dean of medicine and learning the painful process of introducing changes into medical school curriculum, have I realized that I, too, have inadvertently followed the safer path of innovative changes advocated above-without stepping on any baron's toes in the process! REFERENCES I. Rosen CR, Rosekind M, Rosevear C, Cole EW, Dement We. Physician education in sleep and sleep disorders: a national survey of U.S. medical schools. Sleep 1993;16:249-54. 2. Ebert RH, Ginzberg E. The reform of medical education. Health AfJ I 988;7(Suppl.):5-38. 3. Hendricson WD, Payer AF, Rogers LP, Markus JF. The medical school curriculum committee revisited. Acad Med 1993;68: 183-9.
Sleep, Vol. 16, No.8, 1993
