by Arthur Lazarus, MD, MBA July 15, 2022

When I attended medical school more than 40 years ago, virtually all schools taught in a very traditional way: by lecturing on topics and subjects comprising individual courses. We were drilled in anatomy, biochemistry, pathology, pharmacology, and many other courses common to the biomedical sciences.

Traditional lecture-based learning was the norm until around the turn of the century, when there was a gradual transition to teaching medical students by a case-based method. Students began learning about diseases according to systems. Discussing clinical vignettes became central to the curriculum. Students were required to learn aspects of basic science courses that pertained to solving clinical problems and answering questions relevant to the case. The case-based method of learning evolved from problem-based learning and was touted for its deep learning.

There are other advantages of case-based learning too. It introduces clinical material early in the curriculum, links theory to practice through the application of knowledge to cases, and involves learning in small groups with common goals and objectives. Case-based learning mimics the real-world practice of medicine -- especially working in teams -- and learning from cases has been shown to be applicable to a wide variety of fields in healthcare as well as non-medical occupations.

Indeed, case-based teaching was the predominant learning method when I attended business school in the mid-1990s, nearly 15 years after graduating medical school. It was more popular (and appealing) than the lecture format because analyzing problems faced by real companies allowed students to generate their own insights and develop critical thinking and communication skills. Most MBA programs today are case-based -- using Harvard Business School case packets -- and require advanced reading and preparation as well as quality class participation, unlike my experience in medical school, which fostered post-hoc learning and the mere identification of correctly memorized answers from lectures.

The means by which medical students learn -- sitting through lectures or studying cases in peer groups -- bears a strong resemblance to learning to play the piano. Whether the piano is classified as a percussion or stringed instrument makes little difference in terms of how well it is played. The beauty of the instrument depends on the skill and competence of the piano player, which depends, in part, on how well the individual has been taught.

I was taught to play the piano the same way I was taught in medical school: the traditional way. I was taught through notation (reading and playing notes), the equivalent of taking courses and using them as educational building blocks. Practicing and rehearsing musical compositions was similar to memorizing medical facts and minutia; it was a repetitive process that lacked soul. I was force-fed classical music the same way I was mandated to take physiology, histology, and microbiology. I would have preferred playing the Beatles over Bach and Beethoven.

Studying medicine through case-based learning compares to the way children are taught to play the piano (and other instruments) via the Suzuki method -- learning organically by ear rather than notation, and nourished by their parents and other "team" members. For Shinichi Suzuki, it was all about creating the right learning environment, and that placed aural learning at the heart of his method.

Listening skills are likewise essential when it comes to patient care. As William Osler, MD, famously said, "Just listen to your patient, he is telling you the diagnosis." I wonder if I would have been a better piano player -- or doctor -- had I been given lessons through the Suzuki method. I had a "Hard Day's Night" slogging through Bach and Beethoven sonatas. My preference for rock music, which could often be played by ear, was never taken into account by my music teachers.

Whether taught by the case-based method or traditional lectures, medical students must master a vast amount of information in the first 2 years of medical school. Students must acquire a certain level of knowledge so that when they enter their clinical rotations they are well-equipped to apply their knowledge in medical settings.

I find it interesting that the results of the U.S. Licensing Medical Examination (USMLE) Step 1 and 2 examinations for students enrolled in a problem-based versus traditional lecture-based curricula are roughly the same -- both methods adequately prepare students for subsequent phases of their medical education and training. However, students clearly prefer learning from clinical cases and simulation as opposed to lectures. Osler recognized this over 100 years ago when he stated, "I wanted to be remembered for bringing the students out of the lecture hall and onto the wards."

There are pros and cons to traditional versus case-based learning approaches in medicine, just as there are pros and cons to different musical learning methods. I believe the best way to teach medical students is to pick from different methods of learning to ensure there is an adequate balance between theory and practice, instilling an appreciation for the history of medicine and the changing nature of diagnosis and treatment over time.

Although the piano has features of both percussion and stringed instruments, and has been classified in both categories, it is generally considered a combination of the two and is very unique in that respect. Shouldn't the same hold true for the education of future doctors? Shouldn't medical students' learning preferences count, and shouldn't they be taught to integrate the art and science of medicine to be "in tune" with contemporary practice? Roll over Beethoven, tell Tchaikovsky the news.

Arthur Lazarus, MD, MBA, is a member of the Physician Leadership Journal editorial board, a 2021-2022 Doximity Luminary Fellow, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia.

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