Teaching and Learning | Feature
A High-Tech Prescription for Training Doctors
Progressive new approaches to medical education aim to give doctors-in-training more practical, hands-on experience.
For a hundred years, medical education has remained pretty much the same: two years of didactic, classroom-based learning followed by two years of clinical rotations. But now, a rapidly changing healthcare system and exponentially increasing amounts of new data and research are forcing healthcare educators to take a good long look at the state of medical learning in the US. Talk to a few of these educators and some consistent themes emerge: medical learning should integrate clinical practice much earlier in the process, and medical learning needs to be competency-based rather than time-based.
Flipping the Medical School Classroom
It's those first two years of classroom learning that are getting a lot of scrutiny: Students sit passively in lectures without gaining the interpersonal skills they need to work with actual patients. As Scott Helf, chief technology officer and assistant dean of academic informatics at the College of Osteopathic Medicine of the Pacific, recalls, it wasn't until his third year of medical school that he saw his first patient. While this is a common scenario, Helf sees it as one that needs to change.
"What we learn in med school is that 80 percent of a good diagnosis comes from good communication and medical history," Helf pointed out. Establishing good communication and getting a detailed medical history rely on creating a rapport with a patient, earning the patient's trust.
"You have to have emotional intelligence to pick up on the nonverbal cues when you're with a patient," Helf added. "A patient might be there with a cough but be worried about being HIV positive. They're scared. The level of sensitivity is important."
The flipped classroom model is giving students a chance to practice strategic patient-interaction skills sooner. Lecture and other didactic learning is moved online, and students come to the flipped class already knowledgeable about the content. Then, through interaction with their professors, fellow students and a variety of electronic and live simulations, they master that information.
The UC Irvine School of Medicine has supported the flipped model by digitizing just about all of the learning content that students use. Warren Wiechmann, associate dean of instructional technologies and assistant clinical professor of emergency medicine, said that making the content available on iPads means that students have a lot of flexibility around where, when and how they learn.
"This leads to more small group discussion and applied knowledge," Wiechmann said. Students can work through modules at home, including interactive sessions or simulations, then come to the lab for the hands-on piece.
Part of making in-person time more valuable includes rethinking who teaches what courses. Previously, many of the foundation courses at UCI have been taught by professors with Ph.D.s, Wiechmann said, while medical doctors did more of the clinical training. The medical school is finding that M.D.s, who are used to giving impromptu lessons on patient symptoms when making hospital rounds, are sometimes better suited to the flipped classroom because they excel at hands-on learning.
"The real way medicine works isn't multiple choice," Helf noted. "The idea is to get students more quickly through book knowledge to clinical knowledge, when they are thinking as a doctor, not as a student."
Speeding the Process
Another way to give doctors hands-on patient experience faster is by accelerating the time it takes to get through med school. This year, NYU Medical School started offering a three-year degree program for students who commit to a specific residency at NYU. This program covers the same material as the four-year curriculum, said Marc Triola, associate dean for educational informatics, associate professor of medicine and director at the Institute for Innovations in Medical Education, "and it gives students the opportunity to be mentored by the clinical department that they're going into."
Triola pointed out that reducing the time students are in school not only cuts the substantial costs of their education, but also helps students get through all the various stages of medical training and become credentialed healthcare professionals faster.
At Western University of Health Sciences, a switch to competency-based learning is speeding the process for medical students. Robert Hasel, associate dean of simulation, immersion and digital learning for the College of Dental Medicine, noted that many students who come to med school already have advanced degrees in subjects like cellular biology. "Why should they have to sit through basic sciences for nine months?"
Helf and Hasel, colleagues in different departments, have a vision for competency-based learning that relies on adaptive learning technology. As each individual student interacts with the adaptive software, the technology gets to know the student's strengths, weaknesses and primary learning style. It then adapts lessons to provide the information the student needs in the format in which the student learns best.
With this approach, students can proceed through learning segments at their own pace. Some content areas can be quite accelerated, while remedial or reinforcing content is provided to help fill in knowledge gaps. The result is more thoroughly, consistently educated graduates.
Hasel and his team have implemented the Realize IT adaptive learning platform at the College of Dental Medicine. First, they identified the competencies that a dental school graduate needs to have and the different disciplines required to fulfill those competencies. From the competencies, they have generated a list of granular, stand-alone topics that support each competency.
"A topic is like a Lego," Hasel explained. In the dental school, there are about 20,000 Legos that students need to learn. Hasel's team plugged course material into Realize IT's adaptive learning engine, essentially building a wall of 20,000 learning Legos. Thanks to the modular format, if content becomes outdated, it can easily be replaced or revised.
"The engine is built on huge algorithms that are used to assess your path through the content as a learner," Hasel said. "It constantly assesses how you're doing and then it builds a database around you, and guides you to each Lego."
Two people taking the same class with the same expected outcome might go through the material in completely different ways, depending on their individual learning styles, but you can't move on until you master that Lego or that learning node.
Hasel's department has developed a couple of courses on a low-tech gaming mechanism that enables students to interact with the learning material through games of drag and drop, mix and match, hang man and picture IDs, among others. Each chapter consists of four or five games, and students work through the games repeatedly until they get 100 percent on each game. Each chapter culminates in a one-time log on test.
"If you have followed the protocols of the game, you'll cruise through the final," Hassel said, adding that students perform really well in the sections that use the games; the department plans to build more courses this way.
According to Hasel, the adaptive platform has enabled his department to free up seven weeks in the 2,000-hour "classroom" curriculum by eliminating the redundant and irrelevant topics and by integrating the different groups that cover the same content, such as suturing. Now those topics are available as one-time, interdisciplinary learning segments — helping students across the board get through their course requirements faster.
Learning to Deal With Data
NYU Medical School's new Institute for Innovations in Medical Education considers big data and learning analytics as a vital part of the institution's educational mission. That's because in practice, doctors spend almost half their time doing information management, pointed out Marc Triola, associate dean for educational informatics, associate professor of medicine and director at the institute.
"In most cases, that means sitting in front of an electronic medical record, looking through data, ordering tests, synthesizing information about a patient and making sense of it all. And then trying to take a step back, and look at their whole panel of patients and decide what they should or shouldn't do about their practice," he explained.
As part of an 11-school consortium funded by the American Medical Association, NYU is introducing a curriculum for medical students that uses real, de-identified data from the NYU medical center and New York state public health records "to help students learn how to look at all the data, how to understand quality, how to provide safe and effective care and how to make the decisions about not just one patient but a whole panel of patients."