This Date in UCSF History: Two Views On Mandatory Classroom Attendance

Originally published in Synapse on March 14, 2002.

What follows are the opinions of two first-year medical students on mandatory attendance in class and/or small group sessions.

Maybe: by Rita Mukhtar

Invariably, people I know from the “outside world” find it mildly alarming that UCSF medical school classes are graded “pass/not pass” during the first two years.

There seems to be the general desire on the part of the public that “doctors” should work really hard and rigorous training.

People don’t mind hearing about college kids lounging on the beach, but they certainly prefer their medical students cooped up in libraries, and above all, attending class.

It is very possible that the general public is mistaken — that most people don’t really understand the process of medical training, don’t think about things like different learning modalities appealing to different people, and don’t entertain the possibility that trying to learn everything is somewhat unrealistic and possibly counterproductive.

But there is a bit of commonsense wisdom in thinking that participating in class discussions is, for the most part, going to help people learn.

And, while I do so somewhat apologetically, I would even go so far as to suggest that medical schools have an obligation to make some of this class time mandatory.

To say that class attendance should be optional is to posit the conjecture that UCSF’s good name results from the high quality of its students alone — that the admissions process is so competitive, and the standards so high, that anyone who gets in will do well simply because they’re smart enough to learn the material on their own.

While this may be true in part, I would like to think that some credit belongs to the faculty and staff at UCSF — that students graduate with a solid education not only because they were selected to be good, but because the teaching and academic interactions with other students actually enhanced the learning process.

One might argue that a mandatory attendance policy doesn’t necessarily follow that argument — that we’re all here because we want to learn and will therefore attend class of our own volition.

In an ideal world, we would call each other up and arrange to meet and discuss renal physiology — we would create and participate in stimulating, educational groups of our own making.

But I think it’s safe to say that humans have some innate drive to seek out more entertaining pursuits. I don’t know why I never wake up with the desire to study, but I don’t think I’m alone in that.

The truth is that much of what we learn in medical school is tiresome, and realistically, some small groups would probably be poorly attended. We’ve all sat through small groups that seem to drag on endlessly, and entertained thoughts that 20 minutes of independent reading would probably be more useful.

But how can we ascertain the true value of small group discussions?

What if one hour of boredom leads to a breakthrough in understanding that otherwise wouldn’t have come about?

How do we know whether or not some important information is actually leaking through, despite our frustration?

How do we ascribe value to the clinical stories that many small group leaders share as asides?

I don’t think that the answer is to make small group attendance optional and see what happens.

Medical schools are bound by the obligation to assure the public that future doctors are being well, although perhaps forcibly, educated.

I also don’t think that a unilateral attendance policy is the best route. Students demanding completely optional attendance is as unrealistic as faculty demanding 100 percent attendance.

There has to be a middle path which acknowledges that some people don’t get much out of every small group, and that personal obligations sometimes arise, but also that while participating in small group might not be personally profitable, it probably benefits the class overall.

The current situation benefits neither faculty nor students — people aren’t going to be very excited about small group when their attendance is so rigidly enforced and will therefore be less likely to contribute as much as group leaders would like.

Expecting everyone to get 100 percent on every exam is accepted as unrealistic — the same should go for small group attendance.

Why can’t we have an attendance policy that takes into account the fact that people can make their own decisions about what topics will be the most helpful for them, while insuring that people will go to a majority of small groups?

Simply changing the requirement from attending all small groups to, say, eight out of ten small groups would probably go a long way toward this end.

A lot of people would probably continue to go to all of the groups. But some people who really learn better in other ways would pick the groups that they wanted to attend.

And everyone would probably be happier.

Rita Mukbtar is a first-year medical student.

No: by Alex Lee

The more I think about it, the more I realize that professional school is quite a bit like high school. We have the relentless gossip, the cliques, and the fact that we see each other way too much.

On the educational side of school, we’ve moved away from the tried-and-true method of lecture that we were trained in during our undergraduate studies, and partially replaced it with long hours of semi-participatory discussion in dark, windowless rooms, doodling in our notebooks and whispering to our neighbors while sitting in pathetically undersized desks.

The small group experience of watching the seconds slowly tick by as I claw at the bottom of the desk really reminds me of my dark days at San Leandro High nearly a decade ago.

Clearly, I do not get much from small group as it exists here in the New Curriculum of the Medical School. This, of course, is not true for everyone.

My point is simple enough: small group is worthwhile for some, and an incredible waste of time for others.

We should have control of our own methods of learning since we are all ultimately responsible for the same information on the same test and will take the same board exam.

Med students: Slackers?

One of the first pages of the Cancer Block syllabus reads as follows: “The Essential Core Steering Committee has recently clarified its policy concerning small group attendance. Small groups are mandatory.”

It continues on to state that we must contact the course coordinator and the course director prior to the missed session. Not only did this put a sense of fear in me, it also caused feelings of resentment.

Although many medical students might give off the impression that we’re all a bunch of over-partied slackers, the reality is that we actually want to learn the material presented.

Given that fact, it is unfortunate that we are treated as high schoolers. Ideally, we will make decisions of life and death someday soon.

We should be trusted with the decisions of how we learn the material as well. The simple fact is that everyone has a different preferred modality of learning.

Some must be spoken to, some must discuss the information, some must work hands on, some must read on their own, and some must directly visualize the information.

If we have the option of whether to attend and utilize other modalities of learning (lecture, lab, syllabus), why must we be forced to utilize a method of learning that doesn’t work for certain individuals?

In the end, we are all forced to take the same test. What difference does it make if I learned the information from 15 minutes of reading or discussed it for two consecutive hours?

Fundamentally Flawed

As a former high school teacher and university instructor, I realize that small groups can be an incredibly powerful tool for learning. I am also cognizant of the fact that it is incredibly difficult to organize and run properly.

The very fundamental nature of small groups in this present form has inherent flaws that should be addressed.

First, effective small groups must be small enough (ideally five or six) so that each individual student can have the opportunity to actively participate in the problem solving process.

This encourages more one-on-one explanation, discussion, and generally more enthusiasm within the group. This simply cannot occur when there are 15 or 16 people per group. It allows a few students to dominate the discussion and the rest to sink into the shadows (or to sleep, in my case).

Small group tends to work best when creative or collaborative tasks are assigned or problems with no clear answers are debated. Our curriculum has allowed for some debate on social issues and health care, but the average student has no interest in debating molecular techniques for mutation detection.

This sort of topic is better reviewed by an instructor-led discussion or presentation.

It seems that small group leaders have been given the mandate to try to refrain from speaking or instructing, and to actively call on unwilling participants.

For scientific topics without much room for interpretation and debate, such as cancer physiology or renal medicine, a didactic approach accompanied by question and answer time is most effective.

Having a bright medical student attempt to stumble through and teach the group has already undermined the intended purpose of the small group, and has simply replaced a knowledgeable instructor with a student.

In terms of calling on reticent students for questions, and not allowing them to pass, I have last witnessed this technique in junior high when frustrated teachers try to catch napping students off guard, and make an example out of them.

This technique is intimidating, and contrary to the spirit of participation. I believe that this is a pathetically outmoded technique that does not belong in higher education.

A basic tenet of teaching is to change modalities as often as possible. Even a dedicated, focused adult has an average attention span of about 15 minutes.

Two consecutive hours of the same style of discussion is painful. At least in lecture, we are given a ten to fifteen minute break between hours.

Having two hours of small group on five consecutive days on a weekly basis serves to make the average student completely jaded on the process.

To the credit of the new block leaders, small group has been reduced to a mere six to eight hours a week, which actually makes a big difference.

Small Group Leaders: Not Rocket Scientists

If you polled the Med I class on the whether they thought that small group was worthwhile or not, the small-group supporters probably had one major thing in common: they probably had excellent small group leaders at some point.

My point is that there is a huge variety in the knowledge, enthusiasm, personality, and teaching ability of the leaders, which range from fourth-year medical students, to clinicians, to full professors with Distinguished Teaching Awards.

Small group leaders have been removed for going off on tangents, only to be transferred to other groups.

One small group leader that I had for 10 consecutive small groups would gloss over the details of cardiovascular physiology, only to tell us how simple the concepts were.

“It’s not rocket science,” he would say over and over again.

No, apparently it’s cardiothoracic surgery. Group policies also vary widely by group leader.

The lengths of the groups vary from 45 minutes to 2 hours and 15 minutes. Nothing is more painful than watching your classmates in the hall, leaving for lunch at 10:45, while you know that you will be sitting until noon.

Breaks are also varied, from none (most common) to 10 minutes (only if you ask) per two-hour session. Also, attendance is differently enforced by leaders who take absenteeism personally.

Leaders have called absent students or have tried to track them down in lecture to give them extra homework.

Other leaders offer the option of having a friend sign the absent student in. Although there is rotation among the small group leaders, whether you happen to get a good instructor for a particularly difficult span is purely luck of the draw.

Solutions?

1) Make small group 100 percent optional and open. If small group were made optional, several things would happen. First, group sizes would shrink, although not drastically.

Medical students are, for the most part, hard workers, demonstrated by the point that 90 percent of students regularly attend Friday lecture at 8 a.m. (which is optional, of course).

Second, the minority of people like myself who get nearly nothing from the process can spend their time learning more effectively.

Third, all students would get access to the excellent instructors, although I realize this could be a problem logistically.

Fourth, people who enjoy the small group process might have more time to meet in small groups of their own design. Finally, all students could have access to mental health days (i.e. taking the day off) without fear of retribution.

2) As unlikely the first solution is to happen, perhaps the compromise of making 80 percent small group attendance required would be more realistic.

Students would no longer feel intimidated by the mandatory attendance policy, and would get to avoid incompatible group leaders, and take mental health days.

3) Decrease the number of small groups and replace them with other learning modalities. At times, small group simply seems like a time filler.

More preceptorship or shadowing, more patient presentations, more patient simulator training sessions, or even more lecture (god forbid) would be welcome for me.

I cannot count the number of times that there has been incredibly rushed lectures packed into two hours, only to sit and waste time in small group.

Small group can certainly be a good learning tool, but not for everyone.

Until that time, we should be given our freedom, and have our mandatory sentences commuted.

Alex Lee is a former Biology/Health teacher at John F. Kennedy High in Fremont (1998-2000). He has taught undergraduate physiology at UC Berkeley, and has trained physicians in patient management software. He holds a California Teaching Credential, as well as degrees in scientific education and curriculum design. Comments should be sent to aleB@itsa.ucsf.edu