LAUSR

‘How long ... to sing this song?’ [1] Bono’s U2 lament reflecting the tolerance that general society has for injustice could equally be a clarion call against the tolerance medical schools have for learning environments where students feel like ‘leechs’ [2], feeling lost [3] or bullied [4]. Especially given there is evidence that medical student education can be improved, with potential long-lasting antidotes to the decrease in empathy and patient orientation traditionally seen in medical students [5]. Why do we tolerate this? Is it perhaps because as supervisors we were treated this way and have perpetuated it for the next generation – the oppressed have become the oppressors? It is too simplistic for medical schools to blame the doctors. Or is it more a system issue with hospital environments becoming myopic about processing patients and having less regard for learners? It is too simplistic also for medical schools to blame the hospitals. Or could it be us and our teaching structures, which persist in using approaches that are not symbiotic and relationship based [6,7], but rather do take time away from clinicians and involve frustrating repetition of set piece teaching requiring organisational structures that are unnecessarily complicated and therefore demand unaffordable administrative support – a situation disliked by students [2] and doctors alike. Do we need a new way? Can medical training be simplified? Can the academic breadth be captured through technology and the human depth be reinvigorated by longitudinal continuity based apprenticeship [8,9] approaches focused on the transformational ‘becoming’ rather than mere ‘learning’ [10]. Can our assessments (one clear source of anxiety and concern in this article [2]) be more focused on becoming through programmatic approaches [11] rather than mere static judgements of knowledge and skills. Perhaps Maslow [12] may provide us a framework that helps us. As Walters et al [13] described General Practice preceptors valued time taken by having medical students in their practice at the basic level of ‘Safety’ in the Maslow hieirachy [12]. However, if the curriculum is developed in a way that does not take time away from patient care, then higher order needs such as ‘giving back’ and ‘professional recognition’ become the motivating factors for teaching [14]. Walters et al (2008) also demonstrated that longitudinal integrated clerkships [15] met these requirements for the preceptors – they did not have to lose time from their clinical care and they valued highly the higher order belonging, esteem and self-actualisation outcomes. Could there be a similar hierarchy for students? Could it be that students can see and access the higher values in clinical education more clearly if the lower order needs (e.g. personal safety, housing, academic infrastructure, assessment clarity and fairness, academic and administrative support) are met first? Could this explain why students in this study from Bartlett et al [2] were not able to see the valuable personal development that occurred in overcoming adversity? Bartlett et al’s article [2] in this edition of the journal is a timely reminder to us that community based medical education has a powerful role to play in the future training of doctors and prompts the question – is it now unfair, or even unjustifiable, that all students are not provided this opportunity? As Bono pleads, how long will we wait?