“Education is a natural process carried out by the human individual, and is acquired not by listening to words, but by experiences in the environment.”
— Dr. Maria Montessori
Medical education finds itself on the brink of re-invention. Value-based patient care, participatory digital culture, physician wellness, patient satisfaction, the cost of training and the ever-expanding range of knowledge and skills required of the modern physician all speak to the necessity for a new approach. The call for change was formalized in Educating Physicians and continues to be recognized, catalyzing curricular reform initiatives across the nation.[1,2]
As medical educators develop new forms of training, we would do well to consider a long-standing and well-respected approach to education: the Montessori Method. Dr. Maria Montessori was the first female admitted to an Italian medical school and the first female physician in Italy. She was a passionate and tireless educational theorist, psychologist, and advocate for the underserved, who revolutionized the teaching of young children. While there is variability in the approach of various Montessori schools, consider some of the foundational principles considered essential to childhood education:
1. Mixed age classrooms where each learner can work at his or her own pace, unhindered by competition and encouraged by co-operation
2. Student choice of activity from within a prescribed range of options and freedom of movement within the classroom
3. Uninterrupted blocks of work time
4. A constructivist and exploratory model, where students learn concepts from working with materials, rather than by direct instruction
5. Specialized educational materials that stimulate learners into logical thought and discovery, and control error.
6. A learning environment that reinforces, through beauty, order and accessibility, the learner’s independence and natural urge toward self-development.
7. A trained guide or facilitator who is foremost an observer, unobtrusively yet carefully monitoring each learner’s development, recognizing and interpreting each child’s needs to support the process of self-development.
The teacher’s role in the Montessori Method is to initially establish an environment appropriate for discovery and work. During class time the teacher mostly observes. Interventions are made, only when necessary, and then with as light a touch as possible, to maximize exploration, discovery, autonomy, and self-optimization. Students pick stations and exercises that inspire so they may become absorbed in their work. Montessori schools have a unique atmosphere: quiet, focused and serious, yet happy. These learning spaces are beautifully designed for both individualized and community work, sized for comfort and safety, and filled with intuitive and colorful materials to maximize exploration, enjoyment, and learning.
Montessori’s Method provides an ideal framework in which to re-imagine pre/inter-service medical education with four key additions required for adult learning and the modern learner:
1. Education based primarily on autonomous, high-volume, deliberate practice
2. Digitally networked learning studios connecting learners, materials and best practices worldwide
3. Finely grained assessment metrics built into all activities to facilitate data-driven, individualized training
4. Direct and meaningful patient care, system improvement and community service activities
A modern Montessori approach to the medical education environment would require globally networked learning spaces tailored to high-volume deliberate practice for students of all levels and to allow for the quick recycling of best materials and metrics. It would be designed to facilitate autonomous individual and group work with direct observation and support by an expert teacher/trainer and digital access to field expertise. These environments would be developed by curating successful adult workspaces that enliven difficult practice, provide psychological safety, and enhance the particular activity at hand. Google and other high tech firms have both invested and benefited from data driven approaches to providing appropriate architecture and engineering that inspire individual and group work. Medical education should do no less.
Similarly the adaptation of Montessori’s carefully crafted materials for adults are the cases, problems, simulations, projects, and service opportunities that allow learners to explore the landscape of biomedical and clinical knowledge and discover and refine the cognitive, physical and empathetic skills necessary to practice medicine. The key here is for educators to prepare these materials so that they can be used autonomously and asynchronously. That implies, at the minimum, well-edited question answers, practical reasoning and management metrics linked to each activity, a variety of learning experience types, and an attention to beautiful design that will focus and inspire learners. Finely grained assessment and evaluation data is a necessary part of both the learning materials and environment, providing the detailed insight for the expert to support the learner in achieving the full set of skills necessary for modern medical practice and to provide learners with metrics to support deliberate practice.
Students in such an environment are then left to explore, discover, train and inspire as democratic participants in a learning home, responsible for their individual and group success. They maximize their own curiosity, motivation and inspiration while making identifiable, data supported, progress toward clearly defined objectives.
In this reimagined medical education setting, the expert’s role is to observe and deliberate over the progress of the individual and community through direct observation supported by the data extracted from the various curricular activities. The expert, as part of a multidisciplinary learning team, would use this data to determine if students are on track, offer answers to difficult questions, and improve the materials and environment for current and future students — a role similar to that of the clinician-scientist in the hospital or clinic.
By heeding Dr. Montessori’s insights, and providing students with a smooth and autonomous progression toward clinical practice, medical education design can move beyond arguments over clinical versus basic science curricula, online versus in-person learning, or problem versus case based learning; each of these dyads are antithetical only when learning is considered synonymous with rigid and formulaic curricula. When medical students are given autonomy and provided with a full range of beautifully crafted learning experiences outside the clinic, they will naturally optimize their learning trajectory. Only then will learners efficiently and effectively gain the full range of skills and knowledge necessary to develop into ethical clinician-scientists while deeply associating the process of learning with service, curiosity, exploration, discovery, and delight as they progress into the clinical years. And it is this emotional valence to the process that will best serve the end goal of high value patient care and continuous systems innovation. In addition, by adopting Montessori’s approach together with the suggested additional design principles, medical schools will achieve another of Montessori’s aims, an evidence-based education science with the requisite data framework for valid and reliable quality improvement.
Great learning, the type that is self-perpetuating, engaging and inspirational, is a result of service, exploration, and practice, alone and with others. It calls for well-designed learning environments, maximized student autonomy, high-volume deliberate practice, manifold service opportunities and continuous data-driven assessment and feedback. Bedside practice and patient care will always be a cornerstone of medical education and necessarily require limits to such autonomy as well as the thoughtful and direct oversight of a knowledgeable expert. Providing a wide ranging, discovery-oriented and enjoyable learning experience outside the hospital will offer balance. If we, as an educational community, wish to truly innovate medical education for the 21st century, we can start by heeding a brilliant expert from the last, Dr. Maria Montessori.
Benjamin Robison, MD, DMA, Stanford University School of Medicine
Sylvia Bereknyei Merrell, DrPH, MS, Research Scholar, Division of General Medical Disciplines, Department of Medicine, Stanford University School of Medicine
1. Cooke M, Irby DM, O’Brien BC, Shulman LS. Educating Physicians: A Call for Reform of Medical School and Residency. San Francisco, CA: Jossey-Bass; 2010.
2. Asch DA, Weinstein DF. Innovation in Medical Education. N Engl J Med. 2014;371(9):794–795. doi:10.1056/NEJMp1407463.
3. Montessori M. Dr. Montessori’s Own Handbook. New York: Schocken Books; 1965.
4. Ericsson KA, Krampe RT, Tesch-Römer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev. 1993;100(3):363. doi:10.1037/0033–295X.100.3.363.
5. Edmondson A. Psychological Safety and Learning Behavior in Work Teams. Adm Sci Q. 1999;44(2):350–383. doi:10.2307/2666999.
6. Stewart JB. At Google, a Place to Work and Play. The New York Times. http://www.nytimes.com/2013/03/16/business/at-google-a-place-to-work-and-play.html. Published March 15, 2013. Accessed May 25, 2016.