Creativity and medical education

When one thinks of ways of describing one's doctor, `creative' is not necessarily the first adjective to spring to mind. Other words such as `competent' or `professional' or, particularly in the case of surgeons, `brilliant' are perhaps more common. And negative words like `arrogant', `uncaring' or `terse' might sometimes crop up. This is hardly surprising since most aspiring physicians themselves, when applying to medical school, place little emphasis on the opportunity to be creative and original.1,2. `Sciences are learning facts from books and not thinking for yourself. I wanted to express my own ideas and think for myself.' (A-Level student quoted in New Statesman 1994). And yet creativity is an increasingly valuable commodity in higher education. Research dating as far back as 1962 indicates that imaginative, innovative students who are capable of thinking in open-ended ways perform progressively better at university than do those without such abilities.3,4 This is not the case, however, for students further down the educational hierarchy. History indicates that school teachers have not, in general, been patient with the creative type of mind. In a study of 400 eminent men and women, Goertzel and Goertzel estimated that at least 60% of their subjects had serious difficulties in school. Many of them did not get good grades in examinations and many dropped out of school, at least for a time.5 It appears that the foundations of learning, defined here as our earliest and continual experiences of education, are based on a logical-rational approach, at the heart of which is a cognitive style known as convergent thinking, i.e. finding the answer. Much emphasis is placed on this way of thinking to the detriment of others. Many of those who attack ideas advocating a more creative kind of education try to attach the label of `progressive education' to those ideas as a way of damning them. Educational research has repeatedly shown Plato to have been right when he said, `What is honoured in a society will be cultivated there.' This is all very well, but what are its implications for the medical profession? Creativity is increasingly valued in higher education, yet conventional medical curricula actively discourage it. Does problem-based learning go some way toward overcoming this? From the selection of medical students through to graduation and finally practice, it appears that creativity might have a bigger part to play than it has so far been allotted. In his research on what he terms the non-cognitive personal qualities that might be considered when choosing the doctors of tomorrow, David Powis has found creativity to have the greatest predictive validity in determining the success or otherwise of medical students.6 In addition to being logical, orderly and well-organised, Powis argues that the `good' student should also be creative, imaginative and a lateral thinker. These qualities are not mutually exclusive although they are often taken to be. It has been argued that student selection policies that rely on academic marks alone produce doctors with a specific profile of personal characteristics. A six-year study by Parlow and Rothman, for example, indicated that the increasing levels of prior academic achievement in students entering medicine were associated with a declining trend in many non-cognitive dimensions. In particular, the study identified decreases in flexibility, innovation and tolerance of ambiguity, all shortfalls that seem incompatible with requirements for doctors to demonstrate clinical competence.7 Others have drawn attention to the predominant convergent personalities of medical graduates, and to the declining numbers of creative and original divergent personalities. The apparent need of many academic high achievers for a measure of structure in the learning environment is clearly at odds with many innovative and problem-based approaches to study and is not a sound basis for participating in continuing education after graduation.8 `Demonstrated ability in public examinations, particularly the learning, recall and utilization of factual knowledge....is that all that is required to be a good doctor?' (MacFarland 1987) There is growing concern among medical educators that conventional modes of teaching medical students will not produce the `doctors of tomorrow' that society requires. Since a profession's privileged position is awarded by society, rather than being seized from it, and as such may be taken away, it is worth considering whether that profession's practice is out of kilter with societal knowledge and values. This is a delicate and ongoing process and one that clearly serves as a driving force for change, whether explicitly or otherwise.9 The clinical/preclinical divide, still evident in some medical curricula, supports a noted contrast in non-cognitive indices between students who are academically successful and those who are clinically competent. Research by Rhoads et al. highlights the differences: only half the students who excelled in basic science courses did so in clinical courses, while 70% of those who excelled in clinical courses did not do so in basic sciences.10 There has recently been widespread interest in the problem-based learning curriculum (PBLC), where students learn by actively solving problems rather than by passively absorbing information. This builds upon adult-learning principles where the learner's perceived needs serve as a starting point. An important feature of the PBLC involves teaching basic sciences by presenting material in the context of clinical problems, whether real or hypothetical. This serves two goals: it makes knowledge more relevant while fostering the development of specific reasoning.11 A study carried out at McGill University, Canada, has shown that students of new and conventional types of curricula exhibit distinctly different modes of reasoning.12 When asked to give diagnostic explanations of a clinical case, problem-based learning curriculum students displayed a `backward-directed' hypothetico-deductive mode of reasoning, whereas students of the conventional curriculum displayed a more `forward-directed' method of reasoning. Compared with conventional students, problem-based learning curriculum students place more emphasis on meaning than on memorising, are more confident and self-directed in their acquisition of skills, use a more in-depth approach to learning and employ a hypothetico-deductive mode of reasoning which works backward from the starting hypothesis. `Hypotheses', said Medawar in 1964, `are imaginative and inspirational in character; they are adventures of the mind.13 Hypotheses arise by guesswork or by inspiration first and only then, having been formulated, can they be rigorously tested using the appropriate methodology. This is a much more holistic and imaginative process than is given credit for. As Greenlagh says, `Good clinical hunches and competent moral judgements are not simply picked out of the sky. They arise from the same creative imagination that allows the scientist to generate worthwhile hypotheses'.14 The major reforms proposed in medical education over the past decade are beginning to be implemented in new curricula. This has coincided with developments within education in general, particularly in the practices of teaching and learning. These include a sense of partnership and collaboration between teacher and learner, doctor and patient. They also include a sense of self. Many contemporary commentators imply a polarity between the science of medicine (clinical diagnosis) and its art (creating and hearing clinical stories, and making clinical or ethical judgements). Public opinion and perception appears to divide the arts and sciences into two separate categories, impacting not only on how we perceive the arts or science graduate, but also on how they perceive themselves. While the scientist is respected for his perceived authority, he is generally considered to be practised in convergent thinking and to suffer from a lack of imagination: he is regarded as intelligent, reliable and dull. It does a great disservice to the sheer complexity of the human mind, if not to the species, to suggest that we should not be able to emphasize certain versions of self in response to different settings. This is a notion supported by the neuro-scientist Susan Greenfield in her work on the human brain, in which she presents a convincing case for its astonishing plasticity.15 If this is true at an organic level, then it is certainly so at the level of the psyche. Liam Hudson, in his seminal work on ability and self-perception in the arts and sciences, discovered that the converger can be divergent as long as he or she is given clear and authoritative route-signs or instructions that legitimize creativity.4 And, moreover, once this green light is given, the converger can generate more exhaustive and innovative responses than his or her divergent counterparts. The arts and sciences attract and develop different selves and in that process the whole self becomes formed. This is not to say that the formation of one's self is immutable, or that the qualities embedded within our different selves are mutually exclusive. We are far more complex than we have the language to describe. This is what Bleakley means when he declares the person to be a plurality of situated identities that are culturally constituted rather than psychologically or biologically constitutive and unitary: the self is a process in flux, a becoming rather than a being.16 It has been noted for some time that practitioners rely increasingly on their personal clinical experience and the authority of their own senses in their professional evaluations.17 Clinical experience thus consists, frequently, of personal mythology. Personal myths are based on a sense of self in context. The contexts here are medical education, which is currently experimenting with new and innovative curricula, and contemporary clinical practice, which is taking place in new settings that are interdisciplinary and multiprofessional. Traditionally, premedical students were predominantly selected on the basis of science A-Level grades. The declining interest in physical science subjects at A-Level and the corresponding move towards psychology and sociology may imply a possible shortfall of graduates at medical school.18 Either way, the case for selecting students on the basis of ability alone is tenuous and needs to be examined. This, combined with the kind of non-cognitive attributes required in contemporary medical practice, suggests that medical education needs to revise its opinion of the kind of students we want, the curricula we propose to offer and the type of teacher we wish to develop. There needs to be a focus on `fit'. We need to encourage the ability to wonder. Shee Lippell Plymouth, UK

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