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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.

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    10 Comments for this article
    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.
    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.
    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?
    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!
    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
    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.
    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.
    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.
    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.
    In Response to “The Inevitable Reimagining of Medical Education,” Published February 27, 2020
    APS Communications | Linda C. Samuelson, PhD, FAPS, FAAAS
    Dear Dr. Howard Bauchner (in response to “The Inevitable Reimagining of Medical Education,” published February 27, 2020):

    As president of the American Physiological Society, I speak on behalf of a community of nearly 9,000 researchers working in the biomedical sciences. Many of us conduct basic research—foundational science upon which health and medicine are based. So, after reading Zeke Emmanuel’s recent editorial in the Journal of the American Medical Association, I was both intrigued and concerned.

    I agree with Dr. Emmanuel that the evolution of education is well underway, accelerated by the coronavirus. But today, in the midst
    of a global pandemic, never has the importance of basic science been more clear. Scientists are working in partnership with clinicians to understand the mechanisms that drive the virus’ behavior, how it spreads and how patients recover.

    It is times like this—when faced with a new disease that reacts differently than anything we’ve ever seen before—that the vital nature of a robust and thorough scientific foundation for clinicians is evident. We’re learning in real time how critical it is that medical doctors, physician assistants, nurses and pharmacists be well-equipped with a foundation of physiological knowledge that can be immediately applied.

    In recent years, we have seen significant growth in students enrolling in physiology as an undergraduate major. That is a very good thing. But the study of disciplines such as physiology doesn’t and shouldn’t end early on in clinical education. Basic science is the basis of all clinical work, providing structure and context for all that comes after it.

    In addition to highlighting the need for interdisciplinary collaboration and understanding, the virus has also shown us that working in a traditional classroom setting is no longer a given. Distance learning, with its benefits and limitations, is the new normal for now, and this moment in history very well has the potential to permanently change the way science and medicine are taught, learned and practiced. But this change should not include a narrowing of thought, experience or insight. This could easily become a consequence of a system relying on a just handful of experts to be the primary educators of the next generation of medical doctors.

    The depth of understanding that students gain through close study with experienced, working scientists cannot be underestimated or replaced by canned lectures from a handful of researchers—no matter how esteemed they are. The specialization that has been cultivated at the many research centers in the U.S. and around the globe is beneficial to students and prepares them for the diverse array of health and medical challenges that we’ll need to face today and in the future.

    The medical school experience, like so many other things in life, is not—nor should it be—one size fits all. I hope that we can embrace solutions that provide for an expedient path for young clinicians to move into practice. But we should also aspire to a system that provides our young people with exposure to the wide variety of important, fundamental medical and biomedical careers.

    I believe that together, researchers, doctors and educators can find a way to provide a diverse basic science education that turns out smarter clinicians well-prepared to understand, diagnose and treat disease.

    Linda Samuelson, PhD, FAPS
    President, American Physiological Society