The Case for Brutalist Honesty in Medical Education

Introduction

The assumption of a prioi trust between students and institutions of medical education is anachronistic. With current technologies and countless available resources, teachers are no longer gatekeepers to the vast world of medical knowledge. This new access to information, along with an institution’s lack of transparency and tendency to obscure poor student academic results, erodes trust from a student. This can then cause student anxiety as well as the adoption of hidden curriculums to offset perceived risk.^1–6 The emergence of this hidden curriculum can be directly linked to students being unsure of how to succeed in the medical profession,⁴ while, on the other hand, transparency leads to students having stronger outcomes.⁵

Trust is an essential component between students and teachers and can be gained through honest communication, contributing to healthy, respectful, and fulfilling relationships.⁷ Without a fundamental degree of trust within relationships, including those in medical education, the relationship will falter.^1,8–10 To gain trust, a policy of “brutalist honesty” can be used. The term, borrowed from brutalism in architecture, refers to a style of transparency known for its “simplicity, honesty, and functionality”.¹¹

The underpinnings of such an approach are also grounded in moral philosophy and in the methods of establishing trust in healthy relationships. The virtues and benefits of being honest with yourself and others have been noted throughout much of western philosophy, with Kant arguing vehemently for a total prohibition on lying.¹² The logic is that in the act of lying or misrepresenting to another, you are, in effect, taking from them the ability to make a reasoned choice. Therefore, lying impugns the freewill of others. In the case of students, our primary purpose is to prepare them for their future career. Students therefore deserve open information about the state of the curriculum, faculty, and prior outcomes, to be informed in their academic decisions.

Secondly, honesty is the foundation of healthy relationships.⁷ If we want to foster trust in ourselves and in our institutions, we must be open to the notion of absolute honesty towards the students who are committing to our tutelage. The need for brutalist honesty, here rather than perhaps in all personal relationships, stems from the institutional desire to protect itself and its image, along with the difference in power dynamics between a medical school and its medical students. The moral and relational weight of responsibility rests on the institution to provide open information to students.

In this author’s experience, senior faculty have an outdated view of how professional, interpersonal trust is established in the digital era. Classically, when a medical student was admitted into an institution, the faculty and textbooks residing there were the sole experts available. The student’s fate was tied to the local knowledge and pedagogy as there was no counter narrative, and the experience of medical school was encapsulated within that singular institution. It is therefore logical that senior faculty would assume that trust in an institution would be endemic to the experience, as that was their lived reality of medical training.

In contrast, most current students are digitally adept at seeking out information and conducting their own research to advance their career aspirations. Furthermore, they have an overabundance of outside data points to compare their institution’s curriculum against social media posts, corporate products for education and board preparation, medical education podcasts, and instant communication with peers at other institutions – to name a few. Therefore, the marketplace of ideas related to how one should navigate their medical school journey has been drastically increased, often with contradictory academic approaches being suggested. The plurality of choices sets up a tension between the student and institution, as questions arise for the student regarding the justification for the “local” pedagogy compared to the other options, especially in cases where a student is struggling with the curriculum.

In addition to the teachers, in general, we live in a time when belief in long-standing institutions is low.¹³ In running an academic counseling office that directly engages with the curriculum, the author has witnessed a desire from educators and academic leadership to spin negative information, whether it be about the quality of a specific lecturer, the effectiveness and completeness of a course, or the board exam results for a class, etc., into a positive light. The information is parsed in a way which attempts to mitigate any perceived damage, conceivably as a means of mollifying students and protecting reputations. Yet, such an approach is nothing more than an institutionalized form of gaslighting. Based on this author’s inquiries, support for the obfuscation seems to be founded in the ardent belief that if students disregard their apprehensions, cast aside their concerns, and simply follow the program, all will end well. However, there are two major faults that run under the foundation of such an assumption.

First, psychologically, students need to have the core belief that their medical school will properly train them for their future career goals. They require full faith that by putting in the extraordinary effort asked of them, the outcome will be desirable. For example, there is little time to course-correct if there arises a disconnect between a medical school’s content and what appears on board exams, or worse, courses which are passed yet fail to prepare a student appropriately for boards. Fostering a solid trust that maintains healthy relationships – the kind we would like to see between students and institutions – is not guaranteed, and it is the medical institution which seems to take for granted that they should be trusted while avoiding difficult conversations. Medical programs seem to take a Bayesian approach of relying on general outcomes as proof of their efficacy. However, those generalities do little from a student’s individual perspective on if the program will help them succeed, and they risk pushing students into adopting hidden curriculums.

However, the current generation of medical students come from a time where truth has a degree of malleability,¹⁴ and therefore trust in long-standing institutions has to be earned. Furthermore, students feel the effects of the curriculum with or without the institution’s honesty. They experience the growth in their knowledge and can compare that with progress on outside question banks. They also observe their fellow students and the reaction they have to the curriculum. Therefore, even without commenting, the reality of the data (good or bad) is felt by students as they progress through their education.

Second, ethically, students are independent agents. As separate entities from medical education institutions, they should have full access to the information available to make personal decisions. The choices a student makes while in medical school can have drastic impacts on their career prospects. They deserve to fully understand their level of academic readiness, which is likely to unfold and be perceptible, as they progress at their institution. As a field, we cannot on one hand argue for informed consent for patients, in which individuals receiving care should be prioritized as the cornerstone of all health decisions, but then fail to extend that agency of choice to our students who will comprise the next generation of physicians.

Approach

In being hired to rebuild an academic counseling office, the core task was straightforward: to regain student trust. The prior academic counseling office worked with students on improving their studying methods and test taking, but there was no larger context or critique related to how the curriculum functioned, the abilities of faculty, nor when outside resources had proven more beneficial to students than the medical school curriculum. In essence, the truth about the deficits in the curriculum were allowed to be internalized as problems in the students themselves, rather than the student facing predictable struggles given prior class year’s performance.

In order for students to thrive, they needed to be able to trust our advice and support. In earning this trust, it would also encourage and normalize seeking help. Students needed to see that we were on their side and were fully committed to helping them achieve their potential. Our office puts the truth on full and prominent display, both functional and raw. The truth would always be told to any question asked, without regard for the feelings of the institution or faculty. The decision was rooted in the idea that providing unvarnished answers empowers students to have the knowledge to make informed decisions about how they need to approach their own learning, and how to modify their choices over the course of the curriculum. Additionally, the ability to provide critical, but respectful, feedback in a system that utilizes brutalist honesty is an essential skill for students to learn. Opening the door to honesty goes both ways, and students often feel enabled to provide more vocal critiques, even at times the ability to make a case for actionable change, without simply venting frustrations or disparaging faculty.

Starting in orientation, and continuing throughout the four years of their education, we answered everything openly and honestly. We cited historic data on performance in blocks and on medical board exams to answer questions about the curriculum. We told the students when outside materials were perceived as being more effective than ones developed within the institution. We also built our case from the academic literature on the rationale for why students should listen to our advice and worked with them to develop customized plans.

We also promoted brutalist honesty in other ways. When the question arose of whether the curriculum was appropriately preparing students for board exams, we instituted full-length Comprehensive Basic Science Self-Assessment (CBSSA) and Comprehensive Clinical Science Self-Assessment (CCSSA) exams to provide a concrete answer to the students and then followed with individualized learning plans for anyone who felt that they needed additional support. In parallel, we focused on how and why we wanted them to prepare for Step 1 and Step 2, along with the reasons that the suggested strategies might differ from other sources they found.

Lastly, we told all of the students that nothing we suggested was written in stone, we were fallible, and that they could always push back on what was said. Students could challenge us and our advice, without fear, and that disagreement was a part of their learning. At any time, if they felt their approach was better than what we had to offer, they could abandon what we had suggested.

In short, by using brutalist honesty as the cornerstone, we treated our interactions with students as a means to build transparent relationships of mutual respect and gave them information to make better academic choices, all while validating their experience of medical school.

Outcomes

Each spring of the final year before graduation, medical students are given the Association of American Medical Colleges Graduation Questionnaire (AAMC GQ). They are able to rate the office on a 5-point scale from “very dissatisfied” to “very satisfied”. We just finished the four-year curriculum and graduated a class of students who began under this new brutalist honesty approach. Our students reported an improvement in satisfaction with our novel brutalist iteration of the academic counseling office compared to the prior design and philosophy.

From Table 18 of our 2023 AAMC GQ survey data, “Student Support: Academic counseling” showed respondent students who utilized our services had an overall score of 96.2% in the “neutral to very satisfied” categories from that class, placing our support services above the national average of 88.1%. Furthermore, 81.5% of the 2023 class was “satisfied” or “very satisfied” with their academic counseling overall. Perhaps most telling of these results was a 24.1% increase in overall approval from our performance for the 2022 AAMC GQ survey in the same category, where only 57.4% of students responded in the same categories, with an N of 54 for both class years.

Additionally, in comparing student Step 1 performance from the 2023 class against the average of the three prior class years, there was a 9-point increase in scores and a reduction of the class standard deviation by −3.6 points. For Step 2, there was 4.1-point increase over the prior 3 class years average, and a reduction in the standard deviation by −2.82 points.

Taken together, our students report much greater satisfaction with their academic counseling while also performing better on United States Medical Licensing Examination (USMLE) board exams. While the data is limited to only one graduating cohort, the early results are highly promising and suggest that students can make meaningful changes to how they approach the curriculum when provided with early and honest information regarding the institution, improving their overall success.

Yet, our approach did meet some resistance. While, philosophically, such a blunt style of academic counseling might be publicly lauded by leadership, pragmatically, tensions can arise. Faculty morale, institutional reputation, and even personal career aspirations are competing factors for directors and deans. Our office did frustrate some faculty who felt our recommendations failed to support their course designs and that we were contributing to poorer performance within their course. However, as academic counselors, we should reject favoring proximal institutional goals over distal student ones. The failure to admit our own academic shortcomings, whatever they may be, disregards the opportunity to grow in collaboration with our students and fails to foster the holistic relationship that students deserve with their medical education.

Next Steps

The challenges related to adopting a brutalist approach are mostly centered in difficulties in admitting our own weaknesses as faculty. It can be hard to admit that one lacks skills to present a difficult topic as clearly as a YouTuber or a company can, and with those admissions come difficult questions related to self-improvement, motivation, and lack of support for educators. There also becomes the greater question that, in admitting our faults, will that harm the reputation of the medical school, or discourage students from applying? Yet, if we take a step back from our own fears and hubris, recognizing our limitations empowers students to augment their own studies and better prepare for their careers.

Within the academy, we will continue to push for the recognition that the paradigm of medical education has changed and that we should, as institutions of learning, embrace open access to information about our performance to benefit our students. There is not a “one-size-fits-all” solution to succeeding in medical school, and therefore providing students access to extensive information allows them to choose effective methods best suited to their needs. The need for students to correct or augment their education based on the shortcomings of their institution is a real phenomenon, openly discussed by our students, and should be acknowledged by medical schools.

Locally, our goal is to maintain our approach of brutalist honesty to see if student satisfaction continues to remain high, or if given time, the method becomes an assumed trait of the program. We will continue to collect data from our students, elaborating on their satisfaction with our counseling office, specifically on our brutalist honesty approach, as well as other possible factors contributing to their satisfaction.

We will continue to research student perceptions of trust and the impact it has on their academic outcomes. While some of these topics are sensitive and can be difficult to research, a larger effort needs to be made to understand how students internalize trust within their institution and the deeper issues that can arise when distrust takes hold, all in terms of the emotional health of students, time spent on outside educational resources, and overall academic outcomes.