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February 27, 2020

The Inevitable Reimagining of Medical Education

Author Affiliations
  • 1Perelman School of Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
JAMA. 2020;323(12):1127-1128. doi:10.1001/jama.2020.1227

Medical education is currently undergoing a gradual but significant change. Part of the ongoing transformation is reducing the time of education by shortening the preclinical education period from 24 months to 12 to 15 months and, therefore, potentially reducing the total time of medical school.1 Another change is more training in the predominant site of care, the outpatient setting. Additionally, the confirmation and assessment of completed training will shift from time in school to proven competencies. Incorporating all these changes is slow—inordinately slow for many people. But these changes seem inevitable.

Yet these changes are only the start. They do not consider one of today’s most important trends. At many schools, the majority of medical students no longer attend preclinical classes in person but rather watch lectures online.2 Ultimately, it is quite possible that all preclinical preparation will be online, completed anywhere in the world by a multitude of learners from just a handful of the world’s best professors. Students’ competence will be confirmed by a standardized test or set of tests. Then clinical training could be reconfigured, merged with residency training at the medical schools’ affiliated hospitals and, increasingly, outpatient clinical sites. Students will be promoted based on demonstrated clinical competencies, not time in service.

The End of Preclinical Classroom Instruction

At many medical schools, the proportion of the medical school class that attends in-person preclinical lectures has gradually declined. At some schools, unless attendance is mandatory, one-third or fewer students actually attend class in person when they have the option of watching the recorded presentations online. By playing the lecture at double speed, most students “get” the content of a 60-minute class in 30 minutes. They can rewind and review multiple times any portion of the lecture they did not fully grasp the first time through. This learning can be done at their convenience in their preferred environment.

This approach saves students time, provides greater flexibility, and allows more attention to the topics they find difficult. They can group similar lectures together, rewatch them, take breaks while watching, and view the lectures with small groups of other students.

Given the declining attendance at preclinical classes, any rationale for holding live classroom lectures seems to be disappearing. Why should professors give the same lecture on the cranial nerves or pharmacokinetics that they gave last year and the year before for a limited number of students? It is a waste of everyone’s time. Given this trend, the presentations for all preclinical classes should be available exclusively online by 2025 if not sooner.

Once online education becomes the norm, the structure of these preclinical classes will change, too. Sixty-minute presentations are not optimal for online learning. Instead, a series of short—about 6 to 15 minutes—video sessions, each covering 1 or 2 major points with an associated set of readings, is best.3 When preclinical courses are recorded with the primary goal of being used online, the short segments with cases or examples and associated readings could become the norm.

But if preclinical courses transition to being available exclusively online, another dynamic seems to arise. Why should medical students learning anatomy or microbiology or pharmacology be limited to learning from the professors who happen to teach at their particular medical school? Why can’t they—why shouldn’t they—learn from the world’s 2 or 3 best instructors in any particular field? Indeed, medical students already learn pathology from sources such as Pathoma4 and lectures on YouTube. Consequently, worldwide there could be a handful of outstanding courses in each content area developed for all preclinical classes. Medical schools will purchase online courses as the content for their classes, or else students will find the best online courses and learn from them. This approach would allow students to learn from the best teachers in the world—certainly an important goal of education.

Objections to Relying on Online Learning

One objection to moving preclinical classroom instruction online is that there is more to preclinical medical education than basic science lectures. However, basic science courses still comprise 80% or more of preclinical medical education. Much of the additional material—small group discussions, cadaver dissection, and classes on ethics, professionalism, cultural competency, the health system, and the introduction to clinical medicine—also could be well addressed online. For instance, the University of Pennsylvania has available an online class, “The American Health Care System,” with 45 presentations and 5 discussion sessions and an “Ethics of Research with Human Subjects” course with 25 brief, approximately 10-minute, presentations that cover the fundamentals of clinical research ethics.5 These are part of an online master’s program that offers 18 courses. Furthermore, much of the other material, such as cultural competence and communication skills, is really about incorporating clinical content into the preclinical years. Some of this, such as clinical ethics and professionalism, is unlikely to be optimized for students with little experience of clinical encounters. It might better to include these topics in an expanded vision of clinical training.

Online education programs can also offer opportunities for interactive sessions such as synchronous question-and-answer sessions with faculty as well as student discussion groups. With more seamless, reliable technology and, more importantly, advances in augmented reality (AR) and virtual reality (VR), it will soon be possible to “feel” as if everyone in a virtual group is in the same room participating in a single discussion. In addition, histology lectures and slides are already largely online, and digital simulations for anatomy dissection are already available and will improve with VR.

Furthermore, when correctly structured with collective projects or discussion groups, online courses can allow and foster the formation of deep, shared learning connections among students. For instance, at the start of one 20-month online Master of Health Care Innovation program, a 4-day in-person meeting fosters deep esprit de corps among the students and helps facilitate regular interaction and mutual support as the students all proceed through subsequent online courses.5

Another objection is that learning exclusively online is challenging. Approximately 90% of students who start a massive open online course never finish.6 In part this is because online courses currently offer lower rewards for finishing and are not critical for graduation. However, when students have something at stake, such as course credit, retention for online programs is around 70%.7 Arizona State University had a first-year retention rate of 87%, with a 6-year graduation rate of 68%.8 Online training requires real motivation and persistence to learn as an individual.9 But rather than a fault, this is a feature. Being able to finish months of online education in molecular biology, anatomy, and other complex topics is a good test of some of the very qualities that are desirable in physicians—persistence, determination, and commitment to lifelong learning.

If medical students are learning exclusively online during their preclinical training from a few outstanding professors, they will not necessarily have to live in the same city where the school is located but could literally be anywhere in the world with high-speed internet access. This means medical schools will not have a monopoly on preclinical training. Students could complete the preclinical years in any number of ways. Through traditional medical schools. On their own, organizing the right courses. Or, undoubtedly, through new companies that will arise, offering a full suite of preclinical courses by great educators from around the world, facilitating discussions, simulations, and tests. Regardless of the educational path, students’ competency to progress to clinical training will still need to be certified in a uniform manner, such as Step 1 of the United States Medical Licensing Examination.

What Is the Irreplaceable Value of Medical Schools?

If medical schools are not necessary for preclinical education, then why are they needed?

Medicine is irreducibly personal. In the future, there will be greater use of telemedicine, virtual office visits, and other online contacts. Nevertheless, medical care will remain largely an in-person, face-to-face interaction between patients and physicians or other clinicians. Consequently, the clinical portion of medical education will remain focused on hospitals, physician offices, patients’ homes, and other settings. The most pivotal aspect of teaching in these setting occurs in the apprenticeship model, in which an experienced physician and student share clinical situations and the imparting of knowledge and learning are inextricably woven into the actual caring for the patient. Medical schools are uniquely capable of organizing these experiences of clinical rotations with skilled mentors. The irreducible core role for medical schools will be organizing and overseeing clinical education.

Focusing medical schools’ mission exclusively on students’ clinical education will create an important opportunity to reimagine and reconfigure medical education. Students could work on their own for preclinical training and then apply to one institution for both the 2 years of clinical education and the 3 or more years of internship and residency at one of the medical institution’s affiliated clinical sites. The clinical portion of medical training—from medical school through to the end of residency—would then be at a single institution.

Consequently, medical schools could increasingly be responsible for 5 or more years of training, from what now is the traditional third year of medical school through the end of residency. This could facilitate competency-based promotion to internship when students have the knowledge; clinical, communication, and collaborative skills; and maturity to assume the responsibilities of caring for patients.10 In addition, it could reduce some of the redundancy in the fourth year of medical school and internship, as well as some of the potential challenges of geographic relocation between the two.

Conclusions

The unique part of medical school is not classroom-based preclinical training. Increasingly, this educational component will be done exclusively online. Inevitably, that will disintermediate medical schools, leaving them to reconfigure clinical training. Medical school could then be a unified period that incorporates the traditional 2 years of clinical rotations of medical school with internship and residency.

This transformation will not be easy. Transformations never are. But reconfiguration of medical education seems inevitable, fueled by online educational technology and the need to transform clinical training to more outpatient settings with promotion based on competency, not time.

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Article Information

Corresponding Author: Ezekiel J. Emanuel, MD, PhD, Perelman School of Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, 423 Guardian Dr, Blockley Hall, Ste 1412, Philadelphia, PA 19104 (MEHPchair@upenn.edu).

Published Online: February 27, 2020. doi:10.1001/jama.2020.1227

Conflict of Interest Disclosures: Dr Emanuel reported receiving personal fees, nonfinancial support, or both from companies, organizations, and professional health care meetings, and being an investment partner in Oak HC/FT.

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Pathoma website. 2020. Accessed January 27, 2020. https://www.pathoma.com/
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University of Pennsylvania Master of Health Care Innovation website. Published 2020. Accessed January 27, 2020. https://improvinghealthcare.mehp.upenn.edu/master-of-health-care-innovation
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    9 Comments for this article
    EXPAND ALL
    Bridging the Gap of Face-to-Face Medical Education
    Peter Shah, MB ChB MA FRCOpth FRCP Ed | University Hospitals Birmingham NHS Foundation Trust
    Dr Emanuel makes a compelling case for the 'Brave New World' of medical education - there are many benefits to be gained by harnessing technology. The article has caused me to pause and reflect deeply on my own face-to-face medical training, which was inspiring. Is it an unnecessary luxury to be taught in the flesh?

    I believe not. In embracing technology, it is important to hold on to and celebrate that which makes us human and gives us humanity.

    I can still remember the electrifying presence of the best lecturers and the sense of community and camaraderie
    between the medical students in the audience. I can remember the smell and feel of the wooden benches in the lecture theatre, and the expectant hum of the assembled students. I can remember the eye contact with the lecturer and the opportunity to ask questions, and indeed thank the lecturers personally. All these factors contributed to the holistic experience of learning medicine and to the process of embedding the knowledge. It was a rich and inclusive experience.

    What will happen to pre-clinical medical schools if technology makes humans redundant? Where will the next generations of inspiring educators come from in this cut-throat market? How will we police attendance in cyberspace? How will we verify that those who taking cyberspace exams are not being fraudulently represented?

    Technology offers much to enhance learning, but perhaps we need to look at the evidence (still evolving) that the doctors we are producing are fit for purpose. We must retain our powers of critical thinking as we embrace this Brave New World of education.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Future of Biomedical Sc Educators
    Dujeepa Samarasekera, MBBS, MHPE, FAMS, FRCPE | Centre for Medical Education (CenMED), National University of Singapore
    Excellent reflective thoughts. The focus of face-to-face interactions during the early years in medical education and the role of biomedical science teachers should be to

    1. Develop "cognitive skills" such as critical thinking, application, problem solving and

    2. Nurture the humanistic and professional attributes such as empathy, integrity, respect, compassion, humility

    3. Professional identity formation as a student to a future healthcare professional.

    Therefore, there is real value of face-to-face sessions during the preclinical phase of learning. Our biomedical science teachers need to change and see their role different from being just current
    disseminators of basic medical sciences.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Great Description of the Coming Landscape in Undergraduate Medical Education (UME)!
    David Savage, MD, PhD | Cleveland Clinic
    Dr. Emanuel, I agree with this reimagining of the education landscape. It also needs to go hand-in-glove with a reimagining of the UME funding model.

    My medical school had 20-30 students (out of 240) attend most non-mandatory lectures. Yet our faculty still offered the same lecture year-after-year to a mostly empty lecture hall. Most students, as you have described, consumed their content in the study lab with headphones on 2x speed. When the lecture quality was poor, students found alternative resources even if they had to pay for them. I found my peers were very adept at sifting through
    educational resources to pick and choose the best ones for their learning style.

    When we suggested that our school create a curated library of videos from our best lecturers that would not need to be re-made every year, there was pushback. Our suggestion was this: Give faculty protected time to make the best version of their lecture for an online library and then not ask them to record that again until the field and knowledge significantly changes. The counterargument that I heard was that while convenient for students, it would not be possible to justify the "protected education time" or % FTEs that many basic science faculty get for doing teaching/education activities. I believe that most medical schools have pre-clinical faculty who mostly work with medical students and no longer do grant-funded research as a result. How can/should medical schools rethink their evaluation and promotion system so that these educators are not displaced in this new landscape? Where will their value reside if they are not teaching (students will go online for that), not doing grant-funded basic science research, and not seeing patients?
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Ouch!
    Mark Pickin, MB FRCS | Consultant Emeritus Orthopaedics
    Sorry but I have grave misgivings here. How can medical students know what they do or do not need until ten years down the line when they find themselves responsible for something that does not fit the computer protocols and they actually have to try to work things out from first principles?

    Yes.. I discovered early in my student career that I could pick up the content of most lectures in half the time from a book (although, some lecturers who taught more than the facts I never missed) but there can be no replacement for physical lab work,
    dissection, touching things, cutting things, looking down a microscope and actually seeing how things behave and understanding the basic science on which the details and the understanding of clinical medicine hang.

    As a teacher I discovered that final year students and early years doctors were very good at the patient interaction, but ask a question and they often simply plucked randomly remembered factules out of memory rather than trying to work things out.

    Teaching about the shoulder, I used to take them back through basic anatomy, mechanics and pathology and make sure they had all the necessary information to understand what was going on before I started asking questions; about 50% cottoned on to what I was doing and, with them, we could fly and they left understanding not just the shoulder, but why understanding of basic clinical science and, particularly, the inflammatory response is so fundamental to the whole of medicine. The other 50% continued to pluck straws out of thin air and most of these could not even tell me the difference between a PMN leucocyte and a macrophage; one even complained to the professor that my teaching had nothing to do with orthopaedics.
    CONFLICT OF INTEREST: I am retired and would like to know that there will be competent doctors around when I need them!
    READ MORE
    Before Initiating a New Idea, Read an Old Book
    Jerry Miller, M.D. | Prevea Health
    William Osler quotes John Henry Newman in his book, Aequanimitas, “An academical system without the personal influence of teachers upon pupils, is an Arctic winter; it will create an ice-bound, petrified, cast-iron University, and nothing else.” - John Henry Newman
    CONFLICT OF INTEREST: None Reported
    The Only Thing We Know About the Future is That It Will be Different
    Scott Kinkade, MD, EdD | University of Missouri School of Medicine
    The author makes some good points about medical education:

    1. Much of the didactic, factual content can be learned in formats other than live lecture. Things are already moving this way. It just remains to be seen what model will dominate.

    2. Clinical teaching is best done in an apprenticeship model in a clinical setting.

    Unfortunately, preclinical training has much more nuance than just the above. For instance, teaching ethics or professionalism after they have clinical experience gives students more context, but shouldn't they have some preparation before they encounter these situations? Road signs begin
    to make more sense once you start driving, but shouldn't you learn a little about them before you get on the road?

    In this "ideal" curriculum, he proposes to teach Introduction to Clinical Medicine online. While I agree you don't need a clinical setting to teach this, I just don't see how the physical exam and interviewing can be taught adequately via online classes.

    Finally, we are realizing that students benefit from early clinical exposure. Not only does it help keep students motivated and interested, it helps them integrate material, get exposure to role models and start the process of enculturation to the profession.

    I am all for less lectures, but I cannot envision good outcomes when we don't start working with medical students until they are ready for their 2 years of clinical training.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    There are more promising ways to fix this
    Richard Marz, Ph.D. | Medical University of Vienna
    The problem is real, yet there are much more promising pathways to improve the situation.
    1. Students do not learn very much from lectures. The trend towards active learning (flipped classroom) is a sensible approach.
    2. Get rid of the preclinical/clinical divide. Early introduction of clinical content will improve student learning of fundamental concepts - and they will pay more attention. Clinical skills training should start in year 1 of medical school. In the European 6-year curriculum it is also often introduced in year 1.
    3. Small group learning is beneficial on many fronts and I have yet to find
    an adequate on-line implementation.
    4. Putting medical schools in charge of residency training does make sense but only if a strong community-based component can be guaranteed.
    CONFLICT OF INTEREST: I have been involved in curriculum planning for the last 25 years.
    READ MORE
    Osler would be happy with the reimagining of medical education
    Edward Volpintesta, MD | private physician
    Transforming medical education to the outpatient setting would have made Sir William Osler MD very happy. In the early 1900’s in the wake of the Abraham Flexner’s report (1910) on medical education, medical schools underwent much needed improvements their teaching methods. They became more scientific in their approach, employed full-time professors, and became affiliated with universities.

    Osler wanted the training of physicians to be more practical. He wanted the teaching to be done by practicing physicians and imparted in community hospitals.

    Providing training in community health centers will make primary care more attractive to students and improve
    the primary care workforce’s abilities to provide the care that many patients now seek in urgent care center and emergency rooms.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Biggest Impact will be on Transfer to Developing Countries
    David Egilman, MD,MPH | Brown University
    These changes should be shared and co-developed with educational institutions in developing countries. The training must focus on multi-functional teams of nurses, community health workers, lawyers and communities organizers. Medicine is only one component of quality of life and longevity.
    CONFLICT OF INTEREST: None Reported
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