Howard S. Barrows: An Appreciation

“In all of my schooling up and through university and medical school, I never really questioned about how I was being taught. I had good and bad teachers but never thought about good and bad educational methods”—so the late Howard Barrows began his essay on his long and distinguished career as a medical educator. The title he chose was “How an Unsuspecting Neurologist Became Enmeshed in the Field of Medical Education and Beyond.” That essay along with several others was to form part of a collection entitled “Students Matter.”

When Howard and I talked about this several years ago, we were seriously concerned about the growing perception that universities were short-changing students. Several books ^{1 , 2} had recently appeared that condemned universities for short-changing students with their over-emphasis on specialized research to the neglect of teaching. We knew from personal experiences that many faculty relish and enjoy teaching, but students rarely get to see how exciting or fascinating the teaching experience itself can be. We wanted to correct that notion through a series of personal narratives, which we hoped will give students a glimpse into a part of a scientist's life and work that is rarely discussed. So we contacted a number of teachers who had taught students at multiple levels ranging from freshmen to graduate students and professional students. All of them were either physicians or basic biomedical scientists who had found that teaching is richly rewarding. We wanted each essay to be distinct, though the overall theme would convey to the reader the excitement and fascination of teaching at the university setting. The inspiration for this book came from a series produced several decades ago by Annual Reviews, Inc., which gathered together essays by scientists that detailed scientific lives. Unfortunately, Howard passed away prematurely, so Dr. Kevin Dorsey, a close associate of Howard's, and I are bringing out this collection. This would be thus a joint effort between the two institutions with which Howard Barrows was closely associated for the last two decades—Southern Illinois School of Medicine and McMaster University. The authors represent a variety of disciplines (physiology, pharmacology, biochemistry, internal medicine, medical history, neuroscience) and teach in different countries (Portugal, Canada, South Africa, Taiwan, and the United States). We hope that this would be a suitable tribute for someone who has had such global influence.

In the essay mentioned earlier, Barrows discusses his major contributions to medical education—his almost single-handed development of the notion of simulated patients and his participation in the development of problem-based learning. Barrows graduated from the University of Southern California School of Medicine in 1953. Medical education in North America (the United States and Canada) had been codified, standardized and made more rigorous following Flexner's scathing attack on the status of medical schools in the mid-twenties. Prior to the Flexner period, a would-be medical doctor in the early 1900s could choose three paths. He (rarely she) could opt to be apprenticed to a practicing physician or join a proprietary medical school or one of the university-affiliated medical schools. The results were extremely variable and quite scandalous.

Flexner provided the impetus for major medical schools to plump for the university model, which included two years in the basic sciences followed by 2 years in clinical rotations in a teaching hospital. But the post-Flexner world brought its own problems—the focus on basic sciences did not have the expected outcomes.

Here is how Barrows presented the problem:

At the time I felt that the neuroanatomy course taught by basic science faculty was excellent with well-organized lectures and labs that seemed to cover almost all the information in neuroanatomy that students would need. Subsequently, I had contact with the same students who took this course in the first year of medical school when they rotated through the neurology service in their third year. Here, they were expected to apply what they had learned in the first two years to neurological patient problems. I was astounded to find that they could hardly recall any neuroanatomical information relevant to the patient problems they were working with. What facts they did recall were usually incorrectly applied. At least they did remember they took a course in neuroanatomy two years before. This occurred year after year. Faculty in many of the other third year clinical disciplines in this and other schools had made similar observations about the poor performance of third year students in their clerkships. However, they usually attributed this inadequacy to the basic science faculty not teaching what was important. Unlike those faculties in the other disciplines, I was intimately involved in that relevant first year course and knew they did teach what was important and what should have been recalled and applied in the clerkship. They were bright students and I began to think that there must be a problem in the way they were being taught (emphasis mine).

Barrows felt there could be a better way. He developed the model of a simulated patient. This was sparked by his experiences as a neurology resident at Goldwater Memorial Hospital. He wanted to set up a system where professors could watch medical students examine patients without putting patients through the discomfort of that procedure. He remembered one patient who had “faked” his signs so as to get back on an annoying physician. The notion of using actors to simulate finding sprung to his mind. Since he was at the Los Angeles County Hospital, there was a supply of out-of-work actors for this activity. Barrows describes his success with this approach and the animosity it aroused among the medical faculty in the U.S. and elsewhere:

“How can students learn from fake patients?” “A simulated patient could not fool any student WE teach!” Fortunately, I had many opportunities to have simulated patients presented on clinical rounds around the country, and many other countries, to physicians who did not know they were simulated, and the simulation was rarely detected … … In a simulation of a comatose patient, one physician pinched the patient to get a possible response and the patient went into a fit of decerebrate rigidity (as was appropriate), the physician in panic ran out of the examination room and asked for a nurse, an IV setup and appropriate medication immediately. Later, the awareness that it was a simulation dawned on him.

The simulated patient model sought to bring back the focus of medical education to its essential goal, the training of students to become physicians where they could handle patients with confidence. That left begging the issue of the dissonance between basic sciences and clinical medicine. A possible solution came when Barrows went to a meeting on medical education in Toronto, where he met a group from a new medical school that was being formed at neighboring Hamilton. The delegation for McMaster University had heard of Barrows' work and asked whether they could visit him at Los Angeles.

When they arrived in the morning, the Dean of USC's medical school gave me one hour to sit down and talk with them. I became so fascinated by what they were trying to create in Canada and they became so interested in what I was up to that our talk went on for several hours. The Dean finally had to break into the room and tell us lunch was ready. That meeting led to my taking a sabbatical year working with the McMaster curriculum committee and helping design the neurological unit in the medical centre that was to be constructed. A year and a half later, I joined the McMaster medical faculty full-time.

The curriculum committee at McMaster knew that medical students in most schools were turned off by endless lectures by different teachers and an incredible amount of information that needed to be memorized in the first years of medical school. Students considered those years as a barrier that had to be climbed over before they were able work with patients in the clinical years. The reason they came to medical school was to be a physician. The committee members also noted that, in contrast, residents whose learning involved many more hours of work with heavy patient loads and with many simultaneous demands and stresses loved what they were learning. The committee members felt this was because they were working with patients and their problems. They felt that the medical school curriculum, starting in the first years, should be built around patient problems as a stimulus for learning. This seemed to represent a solution to my many concerns about medical teaching with students not able to recall much of what they learned, not able to apply what they did recall and their poor clinical reasoning skills (emphasis mine).

Barrows describes his work at McMaster, and that “in the midst of it all, the title problem-based learning (PBL) for this approach surfaced and was eventually widely adopted.” The essay continues in his inimitable limpid style. He describes his experiences subsequently at Southern Illinois University School of Medicine. He remains astute as ever, wondering whether the term problem-based was itself not problematic. “In retrospect,” he notes, “my career in education developed accidentally and unexpectedly, but I never could be more satisfied.”

If one were to use the standard metrics to assess academics (papers and books published, citation counts, awards received), Howard Barrows was an outstanding educator. He was on the faculty of McMaster Medical School from 1970–1981, after which he joined the faculty of Southern Illinois University School of Medicine, where he retired in 1999 as the Chair of Medical Education. He published over 400 journal articles and 19 books, and he received several distinguished awards: the John P. Hubbard Award by the National Board of Medical Examiners, the Abraham Flexner Award for Medical Education, and the Claude Bernard Lectureship from the American Physiological Society. He co-founded Teaching and Learning in Medicine: An International Journal. His papers, particularly on problem-based learning and the tutorial process, have been widely cited, with several receiving more than 200 citations. But such a listing provides at best a thin description; lost in this listing of facts is the context, the person behind the facts. It fails to capture the grace and humility that so exemplified Howard.

Though I had been at the Faculty of Health Sciences at McMaster University since 1981, I had never met Howard till the early part of 2007. I was trying to organize a symposium on student-centered learning at McMaster and heard through Hal White at the Univesity of Delaware that Howard was living in Hamilton, so I contacted him. He was gracious enough to accept, and his quiet, thoughtful remarks added immense value. After that, we kept in touch, and I would invite him to come to my classes and talk about his educational journey. The students were enrolled in an Inquiry course called Drugs, Devices, and Desires, which sought to deconstruct the antecedents of medical technology. Howard's vivid descriptions of the transformations in medical education made a deep impact on them. They just could not believe that someone who had achieved so much could be so modest and unassuming. He was the master facilitator, quiet, effective, sharp, and critical.

Teachers everywhere bemoan grade inflation, which makes it very difficult for them to gauge true worth. There is inflation of another sort that plagues us. The words “great” and “stars” are thrown around like confetti. Who are the truly great when everyone seems to have that label flung at them? Spender, in his eloquent words, wrote of the truly great: “Born of the sun they traveled a short while towards the sun and left the vivid air signed with their honour.” There is greatness in grace, greatness in humility, greatness in the recognition that one has contributed significantly to one's chosen profession. Howard Barrows, to me at least, was truly great.