SPICES Model of Medical Education
I enjoy reading about medicine. I figured I should read about how medicine should be learnt. What follows is an argument for the more liberal forms of the SPICES model of medical education (Harden, Sowden, and Dunn 1984). The paper itself is relatively old, but many medical schools, especially in the States, have still not seriously re-evaluated their curriculum. Even though newer schools tend to be more liberal in their approach, the inertia of older programs makes the framework oddly current, and therefore still relevant.
The SPICES model is a way of describing a curriculum by placing it on six continua. The acronym stands for student-centered versus teacher-centered learning, problem-based versus information-gathering learning, integrated versus discipline-based teaching, community-based versus hospital-based education, electives versus a standard programme, and systematic versus apprenticeship or opportunistic training. The point is not that every school must live at one extreme, but that schools should be honest about where they sit and whether that position makes sense.
Student-centered vs Teacher-centered Learning
Student-centered learning makes more sense to me. In its simplest form, it means the student has real responsibility over what gets learned and how, rather than acting as a passive receiver of whatever the instructor decides to deliver. It shifts the emphasis from teaching as performance to learning as an activity. I may not always wish to be taught, but I do wish to learn; the paper referenced a line like this attributed to Winston, and it captures the difference well. What matters in education is what the students learn, not what the teacher teaches. If you actually believe that, then you should prefer a model that makes the learner do the work of learning.
The arguments for the student-centered approach are not complicated. It makes learning active rather than passive, and it trains the habit that matters most in medicine: the ability to identify what you don’t know and then go out of your way to fix it. It also allows the student to learn in a way that can actually be efficient for them rather than being forced into a one-size-fits-all method that cannot be guaranteed valuable on the instructor side. Besides, learning on your own is simply more fun. You get to do it your own way, and you get to chase coherence instead of pretending that compliance is understanding.
The objections to student-centered learning tend to be weak. One objection is that many teachers have only experienced a teacher-centered approach. My objection is that this is not a valid argument against the principles of student-centered learning. It’s an argument that the familiar approach is convenient, not that it is better. Education should never be treated with such obstinance. Another objection is that students may be apprehensive because their previous experience was teacher-centered. My objection is harsher: if you’ve never gone out of your way to learn on your own and you feel threatened by the idea, in your lack of curiosity, you don’t deserve to be educated. Deal with it. Physicians have a moral obligation to learn for their patients without being spoon-fed—keeping up with literature, relearning what time has eroded, and updating what evidence overturns. If you can’t do that, don’t become a physician. Student-centered learning emphasizes exactly this form of active learning, and that is why I argue for it very liberally.
Problem-based Learning vs Information-gathering Model
I also argue for problem-based learning over the information-gathering model. Problem-based learning means starting with a problem or condition and using that as the engine that determines what you need to learn, so that basic sciences are pulled in as tools for explanation. The information-gathering model goes the other way: you accumulate foundational facts first, usually sorted by discipline, and only later apply them to conditions. When problem solving in the hospital or clinic, clinical reasoning should trace a path that begins with manifestations—lab tests, symptoms, radiology—and then moves toward potential causes grounded in the basic sciences. Manifestation leads you to mechanism. That aligns naturally with problem-based learning, where you meet the condition first and then learn the causes through a deeper dive, which forces the foundational sciences to become meaningful rather than decorative.
The information-gathering model feels backwards to me. It moves from basic sciences to conditions and asks the student to trust that relevance will appear later. I don’t understand the logic behind this as a default. It feels like a convenient and lossy curriculum derived from textbooks that are demarcated by subject matter, rather than an attempt at an integrated and coherent curriculum. Problem-based learning also helps eliminate superfluous information, because every piece of foundational science you learn should be required for a full explanation. It is far too common within education to learn unnecessary information simply because it exists, not because it is needed.
The common objections to problem-based learning are also predictable. One is that you need a solid foundation first, and vocabulary matters, as emphasized in the information-gathering model. I don’t understand why you can’t do this within problem-based learning. If you dive deep enough into any clinical problem, you will always find the foundations, and you will learn more than enough to explain pathological phenomena. And vocabulary is easy. Learn the medical Latin and Greek roots and you’re good; it isn’t too difficult to intuit what a structure or process is once you break the word into its component roots. Another objection is that problem-based learning places a heavy load on instructors because it requires well-prepared, integrated material aligned with problem solving. That’s understandable, but it’s not an argument against the principles of problem-based learning. It’s an argument for the avoidance of such practices, which is a different thing.
Integreated vs Discipline-based Teaching
In the same vein, I argue for integrated teaching rather than discipline-based teaching. Discipline-based teaching segments medicine into separate subjects—anatomy here, physiology there, pathology somewhere else—and then expects the student to assemble the overall picture on their own. Integrated teaching attempts to interrelate these areas deliberately so that the student is not forced to do all the synthesis after the fact. Integration can be horizontal, meaning integration across disciplines at the same stage, like learning anatomy and physiology together within a system, or vertical, meaning integration across time, linking basic sciences with clinical thinking rather than pretending basic science ends when the clinic begins. The integrated approach aligns with problem solving because adequate explanations for real conditions usually require multiple disciplines at once. The body does not respect departmental boundaries, so education should stop acting like it does.
One of the better points the paper makes is that integration promotes communication between instructors across disciplines. It forces them to think about the overall aims of the curriculum and of the school rather than being limited to their own departments. That shift matters. Departments have incentives to defend their subject-matter territory, but students need coherent models, not territorial claims. Integration is one way to force the curriculum to admit that coherence is the actual goal.
There is, however, one objection to integration that I take seriously: it can be lossy. Since the integrated approach focuses less on the individual subjects and argues for a holistic approach, some information is bound to be lost. Whether that loss is dangerous is another debate, but the possibility is real. The omission of topics must be closely monitored, because “integration” is not a license to be sloppy. Another objection is that teachers are often more passionate about their own subjects, which could decrease enthusiasm in an integrated structure. Even if that happens, instructors should still be able to see the overlap between their own field and other fields, and they should be capable of teaching their piece as part of a whole. Another objection is that integration may induce uncertainty about which specialty a student should choose. I don’t understand the basis of this argument. Specialty choice is not based on book learning alone; it is shaped by experiences during rotations, mentorship, temperament, and the realities of daily work.
Community-based vs Hospital-based
I argue for the community-based approach over the hospital-based approach, but this is simpler than the other debates. Hospital-based education concentrates pathology and acute care, but community-based education is closer to the actual distribution of medicine: prevention, chronic disease, early presentation, follow-up, and the social context that determines whether treatment matters. If you train only in hospitals, you risk confusing the most intense slice of medicine for the whole of medicine. Community-based education corrects that distortion.
Elective vs Uniform
I also argue briefly for an elective-based curriculum. Electives add an element of responsibility and ownership, and they acknowledge that students do not all need the same depth in the same places at the same time. They allow exploration and the pursuit of specific interests without pretending that a uniform programme can optimize for every future physician. A standard core is necessary, but a purely standard programme assumes a single path, and medicine does not reward that assumption.
Systematic vs Apprenticeship
Finally, I argue for a systematic approach over the apprenticeship or opportunistic approach, because uniform coverage matters. Opportunistic learning depends on chance: which patients arrive, which cases happen to be on the ward, which attending happens to teach, and how service pressures distort teaching. A systematic curriculum is a commitment to ensuring that required experiences and competencies are covered rather than left to luck. In real medical settings, gaps are not just personal deficiencies; they become risks that bleed into patient care. If education is supposed to be ethical, then it cannot rely on accident.