Bok's Annual Report Draws Praise and Pointed Criticism

In the three weeks since its release, President Bok's annual report to the Corporation, which this year focused on medical education and on Harvard Medical School in particular, has received widespread attention, and most reactions are either strongly positive or negative.

While many faculty of Harvard Medical School and other prominent medical schools said they were pleased with Bok's recommendations, which include a restructuring of medical curricula to deemphasize the basic sciences and an addition of more humanities and ethics courses, some added that their complaints lay in his suggestions for remedying the problems.

"He identifies where we want to be, but not how we're going to get there," Jerome L. Avorn, associate professor of Social Medicine and Health Policy, said yesterday. He echoed similar comments from other faculty that Bok did not provide a clear directive for action in "humanizing" medical education.

Generally, many faculty and administrators agreed that Bok had addressed the most significant issue now facing medical educators.

"I'm in total agreement with his identification of the problems," Dean of Cornell Medical College Dr. Thomas Meikle said this week, adding "[Bok's] recommendations for change and improvement were right on target."

The president's report focused on both the heavy pressure placed on undergraduate premed students by the competitive nature of medical school admissions, and on what is widely viewed as an overemphasis by medical education on the so-called "hard," or basic, sciences.

Bok's recommendations included fewer lectures and smaller classes in the first two years of medical school, and a call to add ethics to the general curriculum.

New Pathway

The report praised an alternative program the Medical School has been developing, designed to alleviate pressure on pre-meds and to integrate humanities and basic sciences. The "New Pathway," which will accept 25 students on an experimental basis in the fall of 1985, is a five-year program, extending into the first year of residency. Modeled on the progressive system at the McMaster University Medical School in Toronto, the program will be case-based, emphasizing the study of specific incidents rather than broad-based disease analysis, with lectures limited to one per day.

"Students will see patients practically from the first day of med school," said Eleanor McLoughlin, the Medical School's curriculum coordinator. She added that "ethics will be fundamentally incorporated" into the new program.

While many Harvard faculty agree that ethics ought to be taught in the classroom, some hasten to add that students can grapple with difficult issues best with day-to-day practice.

"Ethics shouldn't be taught in a formal course context," said Medical School Dean for Students and Alumni Daniel D. Federman.

"If I'm teaching, and one day we go to visit someone who has a difficult problem, we talk about it right then--whether or not there's been a lecture, there's been an ethical decision within a medical contest," he added.

But in an era of great technological advance that has given rise to difficult judgement questions, some educators are skeptical that any less than drastic changes will have a real impact on students' sensitivity to the growing problems of ethics.

Presley Professor of Psychiatry Leon Eisenberg said last week the "the central question is this: how much difference in physicians' behavior is determined by medical education, and how much by the conditions or practice, and the society in which they work?"

He cited the vast monetary rewards for some areas of medicine as detrimental to the ideals of the field, and added that "government and public health ought to be the aim of medicine, rather than the enrichment of physicians."

While doctors differed on what factor they thought was most responsible for medical education's insufficient preparation of students for practice, most said they believed Bok's report identified the major areas of concern.

But while most agreed with Bok's claim that attitudes and practices in medical education are so ingrained that the Medical School faculty may resist change, officials disagreed about the central problems of poor teaching.

Meikle said he "took issue" with Bok's claim that faculty are unwilling to upgrade their teaching methods primarily because there is very little reward for teaching.

"I believe academic promotion must be based on a professor's productivity in worthy scholarship. And teaching should be part of the basic portfolio that someone brings into a college or medical school," Meikle said.

Avorn agreed, noting that one point Bok's report did not fully address was the promotion of teachers on the basis of research, a phenomenon he said predominated at Harvard schools, and particularly the Medical School.

"How can we have a system of promotion and appointment based solely on research output and expect good teaching?" he asked, adding that there is no necessary correlation between good research and effective teaching.

He added that he wrote a letter to Bok immediately after the release of the report expressing his concern with teacher valuation, but that Bok responded that he doubted very much would change in the near future.

Too Good

Although many doctors and administrators said they thought it was appropriate for Harvard to make a statement on such a significant issue, because other schools will follow Bok's lead, A vorn added that the University's stature may in fact be detrimental to any efforts at broad change here.

"I sometimes fear that the national impact [of the report] may be greater than that at the Med School," he said, adding "in some ways all this would be much easier if we weren't so successful, didn't have the great [research] track record we do."

Smaller schools, he added, have more room for change because they don't receive the enormous research grants that Harvard does, creating expectations for research output.

"Pragmatically, [change will be difficult because] the economic inertia and enormous success of HMS will carry the day. But only time will tell," he said