Dr. Howard Barrows was one of those medical educators who many of us believed would live in perpetuity. The news of his passing was not only sad, but shocking. Another one of the giants in medical education research and development silenced.
Dr. Barrows's contributions to medical education have become so much a part of the fabric of medical education, they are almost ubiquitous, and certainly, those new to the field of medicaleducation may not associate his name with much of what they encounter in their everyday curricula. Howard contributed three foundational elements to modern medical education: human simulation, performance-based testing, and problem-based learning.
Standardized patients originated in the early 1960s when Howard was a young assistant professor of neurology and had the support of one of the earliest division of medical education research directors, Steve Abrahamson. Barrows developed the idea that an ordinary person could be recruited and trained to portray a neurological disorder. Thus standardized, the “programmed patient” then could be used to evaluate each clerkship student's ability to do a complete neurological workup. Simulated patients were the predecessor to a paper simulation called the P-4 Deck, which became what many schools now know (and may own) as the Problem-Based Learning Module (PBLM), or ePBLM. Needless to say, human simulation has expanded beyond medicine and continues to evolve. Could there still be a medical school in the country that does not use some form of simulation?
The use of simulation evolved from an instructional form into an assessment format that has forever changed the way that medical students and residents are assessed, promoted, certified for graduation, and licensed. The clinical performance examination was developed with the collaborative efforts of other faculty at Southern Illinois University School of Medicine for its graduating seniors in the mid-1980s. Dr. Barrows invited a panel of national experts representing the Association of American Medical Colleges (AAMC), the Liaison Committee on Medical Education (LCME), and the National Board of Medical Examiners (NBME) to vet the School's performance-based examination in preparation for demonstrating it to every U.S. medical school through grants from the Josiah Macy Junior Foundation. For the first time, medical schools could reliably replicate presentations by individual standardized patients, which enabled the stringing together of numerous student encounters with different patients and the assessment of the quality of these interactions as a measure of student achievement—indeed, the very kinds of patient encounters with which faculty expected students to demonstrate competence. For these pioneering efforts, Dr. Barrows was awarded the first John B. Hubbard Award in 1984 by the NBME.
Believing that the true essence of learning is to be found in the workplace, Dr. Barrows, in conjunction with colleagues at McMaster University, developed problem-based learning in the 1970s. This student-centered, small-group learning with actual patient cases had its most rapid dissemination in medical education but has been implemented at every level of professional education and is a growing presence in other forms of education, including K–12, both in the United States and abroad.
In addition to his leadership in medical and neurological education, Dr. Barrows was also a prolific researcher and writer. With others at McMaster and Michigan State in the early 1970s, he conducted basic research on the clinical reasoning process, which likely formed the platform for PBL, as well as his other educational inventions, and subsequent research by others on clinical expertise.
He and his work have been highly influential on those of us who were lucky enough to work with him, as well as educators worldwide. It was not always easy for Howard, whose vision and eagerness to move ahead often created tension and sometimes hostility among the faculty, but his response was always as the veteran tutor, operating at the meta-cognitive level, in hopes of moving faculty in the same direction: questioning, seeking evidence, reassuring colleagues, and remaining firm. He was a wonderful mentor to so many educational researchers, urging us to take the next steps to improve the foundations he laid and leaning on us when necessary. This mentorship manifested itself in two additional ways. Through collaborative arrangements with the University of Illinois, Springfield, he began a program that permitted interested educators from around the world to work with SIU faculty and to simultaneously earn a master's degree, and he, along with Terrill Mast, Ph.D., was founding editor of this journal, Teaching and Learning in Medicine, which began its quarterly publication in 1989.
In addition to the Hubbard award, Howard was also the recipient of the Abraham Flexner Award from the Association of American Medical Colleges for outstanding lifetime contributions to medical education, the A. B. Becker award from the American Academy of Neurology for lifetime achievement in neurological education, and the American Education Research Association's distinguished career award from Division I: Education in the Professions. He was also inducted into the McMaster Medical School Faculty of Health Sciences Community of Distinction. Howard was most recently Professor Emeritus of Medical Education at Southern Illinois University School of Medicine.
Howard was the epitome of a lifelong learner and a true Renaissance man. Not only was he a skilled neurologist and medical educator, he had a keen appreciation for art and music and was himself an artist, harpsichord player, photographer, cartoonist, and tarot card reader. He and his wife, Phyllis, were true soul mates, and those of us who were fortunate enough to know Phyllis were lucky!
It is difficult to imagine what medical education would be like today without Howard's vision and leadership. What we can imagine is that Howard's legacy will continue to influence medical education research and development for years to come.