Appendix 12a - Regurgitation

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]

"Trying to take in what is now delivered in medical school is like trying to take a drink of water from a firehose."[164]

For a number of years before retirement, Ludwig W. Eichna, a department of medicine chairperson, went back to medical school in order to offer a unique perspective on medical education. His findings:

[Medical school] consists largely of too much fact in too little time, which is maldistributed to boot.... The gobs of facts delivered during the science years leaves little time for thinking. Students detest it, yet by habit they gobble the facts. Disillusion-ment results.... Fatigue, somatic and cerebral, dulls the will and the edge of thought.[165]

This is a common sentiment. From Becoming a Doctor: "Too many facts are being taught too thoughtlessly, in too short a time."[166] A student in Doctor-to-be writes:

Like a dry sponge in an ocean you swell courageously with information that seems always relevant and fascinating until every pore of your being is engorged and a wave crashed your tiny remains into the drowning darkness. Oh, sure, there is a lot of information that you need to be proficient at your job; well suck it up, others have done it. Yes, but we all have scars.[167]


Much of the anxiety students put themselves through revolves around a myth that most of the information is relevant, indeed vital, to their future as doctors. From The Healer's Power:

The rescue fantasy is a power trip: it envisions the physician having the power to snatch the patient from the jaws of death. Probably most students are possessed by it to some degree upon entering medical school and it is part of the popular folklore about physicians. In the days of old, at least, it was implicitly used by medical school professors to spur students on to greater efforts; unless you listen carefully to my lecture about the hexose monophosphate shunt (said the biochemist in so many words), someday you will kill a patient.[168]

Memorize and Regurgitate

Ultimately, success for the medical student becomes the ability to memorize extensive checklists.[169] From the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research:

Especially during the first two years of medical school, intellectual thought may be stifled because the expectation (as reflected in exams) is that students simply memorize and regurgitate rather than learn to apply information and concepts to solving problems.... [Furthermore] students are taught about bodies as though the minds, emotions, and lives associated with those bodies were irrelevant.

From an article published in JAMA:

Analysis of the accumulated data revealed... that students want to learn meaningfully, that is to understand and be able to recall a subject, but resort to rote learning (i.e., memorizing without understanding) to pass examinations in the allotted time. The amount of rote learning taking place in most medical schools may be a major reason third-year students lack the expected understanding.

As one fourth year student put it, "Learning by memorization means engraving an equation, dictum, or passage from a textbook or lecture into my mind, repeating it over and over until I can spew it out on cue, delivering it like a worn chant and yet not comprehending a word of it." Learning by rote, however, usually suffices to pass multiple-choice exams.[170]

Quoting from the Canadian Medical Association Journal, "We must respect the intelligence of medical students in expressing opinion rather than regurgitating facts. We must acknowledge that examinable facts will always exist in texts but compassionate spirit never will, and once lost it may never be recovered."[171]

It is unnecessary - perhaps dangerous - in medicine to be too clever - Sir Robert Hutchinson

According to one hospital chairperson, medical school education is today permeated by an "air of anti-science, even anti-intellectualism."[172] For many students, quoting from an article in Harper's Magazine, the, "courage of independent thought falls victim to all-night study sessions, overwork on clinical rotations and external and internal criticism...."[173] From Doctor-to-be: "For the brilliant, creative students, lockstep curricula may contribute to their emotional breakdown. They find it almost impossible to conform to unimaginative teaching."[174]

Who Dares to Teach Must Never Cease to Learn

To extend the spirit of inept teaching into the clinical years, an article describes a set of satirical instructions for clinical faculty. "Adhering to them consistently produces courses that fail to teach."

1) Make sure the students are always in slightly over their heads.... Accomplish this goal by sending students off to departmental grand rounds without preparing them for the subject beforehand or bothering to discuss it afterwards.... Do not concern yourself with the students' prior educational experience or potential clinical needs.

2) Similarly, on a surgical rotation, drill the students on the historical names and backgrounds of various retractors, forceps and clamps.... Programs such as these usually produce frustrated fuzzy failures....

3) The apocryphal guru who said that the educators should determine what the students need to know and students should determine how they can best learn it was just a trouble-maker. Keeping goals and objectives fluid produces a consistently nebulous type of failure.

4) Providing a whole parade of stars for one-shot contacts should help the students avoid a consistent, sequential, and orderly sense of a subject.... Moreover, it is important to keep the students among strangers, to decrease the likelihood of any cohesive experience.

5) The faculty need hardly be reminded that their rallying cry of, 'I refuse to spoon-feed the students,' can always be used to counter accusations of poor preparation or unclear presentation.

(Same with not wanting to teach "cookbook medicine." God forbid we learn some basic recipes to follow before improvising - that might take some of the mystery out of it.)

6) Be boring, and do not amuse, excite, or engage the student.

7) Assign useless rites of passage.

8) Keep students away from your house. Never invite them for dinner. Having them over only decreases their anxieties and makes their learning more interesting. Rather, focus on the motto, 'familiarity breeds contempt.' Avoid meeting any of their dependency needs. To produce an early and consistent failure one must prevent bonding with viable role models.

From Academic Medicine: "Some of the educational consequences of the 'overstuffed' and often poorly taught... curriculum where non-thinking is the rule are well known, and include overloaded and overwhelmed students who... [regard patients] as the enemy.'"[175]

Us versus them - Appendix 12b.


[164] Rogers, DE. "Some Musings on Medical Education." The Pharos 1982(Spring):11-14.

[165] Eichna, LW. "Medical-School Education, 1975-1979." New England Journal of Medicine 303(1980):727-734.

[166] Konner, M. Becoming a Doctor: A Journey of Initiation in Medical School New York, Viking, 1987.

[167] Knight, JA. Doctor-to-be: Coping with the Trials and Triumphs of Medical School New York: Appleton-Century-Crofts, 1981:8.

[168] Brody, H. The Healer's Power Danbury: Yale University, 1992.

[169] Ward, NG and L Stein. "Reducing Emotional Distance." Journal of Medical Education 50(1975):605-613.

[170] Regan-Smith, MG, et al. "Rote Learning in Medical School." Journal of the American Medical Association 272(1994):1380-1381.

[171] Nisker, JA. "The Yellow Brick Road of Medical Education." Canadian Medical Association Journal 156(1997):689-691.

[172] Eichna, LW. "Medical-School Education, 1975-1979." New England Journal of Medicine 303(1980):727-734.

[173] Duncan, DE. "Is this Any Way to Train a Doctor." Harper's Magazine 1993(April):61-66.

[174] Knight, JA. Doctor-to-be: Coping with the Trials and Triumphs of Medical School New York: Appleton-Century-Crofts, 1981:328.

[175] Regan-Smith, MG. "'Reform Without Change.'" Academic Medicine 73(1998):505-507.

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