Alexander Mafi: All sizzle and no stake—why medical school feedback needs a revamp

Medical students should have collective input into how their courses are designed and led, says Alexander Mafi

Ideas, concerns, and expectations” has become a staple of medical training on communication skills. The idea? To move away from the paternalistic ethos of “doctor knows best” and encourage patients to take ownership of their own health. The concern is that when we as doctors tell our patients what to do without factoring in their own thoughts and worries, they will disengage both with us and the care we are imposing on them. And yet, as students, we are taught in medical schools that are paternalistic in nature. We are handed a syllabus at the start; an exam date for the end; and we are rarely asked our ideas, concerns, or expectations about our course. If paternalistic medicine is out, perhaps medical education needs to catch up? 

“Name one thing that could be improved”

Traditional medical school teaching is primarily designed by professors and consultants, who decide what we learn and, by extension, what information holds value. Through lectures and seminars, this information is then often imparted by transmission—they talk and we listen. This mechanism of learning sits in stark contrast to adult learning theory,1 a cardinal principle of which is self-directed learning. Its developer Malcolm Knowles has outlined some integral components: mutual assessment of learning needs between student and teacher, learning through inquiry, and mutual measurement of programmes. Quoting behavioural science research, Knowles explains how our engagement in a learning activity is proportional to the level of involvement we have in its planning and construction. Or to frame it another way, the less input we have into what and how we are learning, the less engaged we will be. 

And yet, “Thanks, could’ve been shorter” scrawled onto a generic feedback form is the extent to which many of us have contributed to our medical education. Of course, this is not true everywhere and for others this process is more meaningful, as tutors and lecturers actively engage with students to gain feedback and improve their course. These mechanisms typically, however, remain reactive, passive, and unilateral. We’re asked to vote on the changes rather than designing the changes ourselves, to give feedback on outcomes rather than deciding those outcomes at the outset. 

This is not to say that expertise is obsolete, far from it. I have little doubt that the experience and knowledge of consultants and professors should continue to play a dominant role in curriculum design. What I am arguing is that it shouldn’t continue to play the only role. Just as patients have their own ideas about their health (experts in their own right!), so too do students have our own ideas about our learning and development as doctors. 

My colleagues and I took curriculum design into our own hands last summer when we gave feedback for improved diversification and representation within the medical curriculum. Not satisfied with the response, we designed our own lecture and scenario workshops (recruiting 60 final year students to help teach them) that highlighted issues around ethnicity, sexual orientation, gender, belief systems, and socioeconomic status in the healthcare setting. We began conversations about how patients from different demographics may have different experiences of healthcare and how we as future doctors can contribute to that, both at an individual and an institutional level. 

The new age of participation

In their book New Power, Timms and Heimans examine the rise of new power in a world still dominated by old power structures. Old power is that held by the few, the “experts.” It is “closed, inaccessible, and leader driven.” It is the careful guarding of curriculum design by a select few and the top-down dissemination of information. In contrast, new power gains its energy from communities and the groundswell of people, from participation and from openness. It looks like the open letters sent to medical schools nationwide in support of the Black Lives Matter movement; the 60 final year students leading teaching on topics that they wanted covered; the student at St George’s University who designed their own textbook when the ones supplied to them were inadequate.  

Medical students should be more than just consumers who leave reviews. We need to be participants who have collective input into how our course is designed and led. 

This participation could manifest in a hundred different ways. It could be student led teaching, integrated into the course, with older students teaching aspects of medical practice they feel strongly about. Or students, patients, and professors routinely sitting around a table unpicking and redesigning course structures and contents. Or even the publishing of the curriculum for students, patients, and the public to scrutinise alike. The benefits of this would be abundant. Students would enjoy newfound opportunities to teach, to design, to frame problems, and to determine value in medical knowledge. Meanwhile, medical schools would unleash a new surge of energy from students—no longer the products of a system, but its very building blocks.  

This is new power and it can’t come soon enough. The practice of medicine is changing, and medical schools must change with it. 

Alexander Mafi is an F1 doctor training in Manchester. He has an interest in inclusion and representation in medicine and medical teaching, and in improving the experience and outcomes of patients and staff who identify as being part of minority groups. 

Competing interests: None declared.

Acknowledgements: Thanks to my colleagues Sumaiyah Al-Aidarous and Zara Markovic-Obiago for co-leading the “Diversity in Healthcare” initiative and Margot Turner, senior lecturer at St George’s university, who helped us design it. 


  1. Knowles MS, Holton IEF, Swanson RA. The adult learner: The definitive classic in adult education and human resource development. A Butterworth-Heinemann Title. 2005.
  2. General Medical Council (UK). Tomorrow’s Doctors. London. 2009.
  3. Heimans J, Timms H. New Power: How Power Works In Our Hyperconnected World – And How To Make It Work For You. New York, USA: Random House Large Print. 2018.