The Transformation of Medical Education

Yesterday I read an article by Ezekial Emanuel, a professor and former adviser to President Obama on health care policy. Dr. Emanuel is a very nuanced thinker and had some great ideas around the time that the Affordable Care Act was crafted. He speaks out about how rising healthcare costs stem from inefficiencies, wasted testing and treatment and perverse incentives that encourage us to do what is expensive and ineffective rather than what is cheap and effective. He tells difficult truths. So I read his article, "The Inevitable Reimagining of Medical Education" in February 27, 2020 JAMA magazine with great interest. Medical school is painful and expensive and produces some pretty bad doctors so could definitely benefit from some reimagining!

I learned that medical education is already being changed in ways that are hard to imagine and that it may become nearly unrecognizable. To which I initially said hooray, but am reconsidering.

Medical school, when I attended it in the mid 1980's, was 4 years of tightly packed education. The first year was spent learning very basic science, including biochemistry, anatomy and physiology. How the normal body functioned. The second year we learned how the body functioned when diseased and learned about the many disease processes and how they are treated. We memorized lots of lists and were taught by experts in the different scientific fields who were usually also good teachers. We attended classes from 8 AM to about 5 PM and then ate dinner and studied. The second two years were spent in "rotations" in which we shadowed doctors in all of the major specialties and helped with patient care while learning to do the physical portion of being a doctor. We learned to draw blood, examine the blood as well as urine, stool and pus under a microscope. We learned to place sutures, do minor surgeries, deliver babies, take notes, present cases to attending physicians, help patients in their dying process. We did lots of things those last two years and we didn't sleep very much. We attended lectures but they were mainly about the complexity of disease and its treatment. We then took a high stakes licensing test and were distributed into residencies where we, as newly minted MD's, were mentored in the process of becoming independent doctors in a specialty. That process took anywhere from 3 to maybe 6 years. Then we were done, golden brown and with a hollow thumping sound when you tapped our undersides.

It was painful and difficult and the amount of information that we needed in internalize was tremendous. I was depressed, thin, pale, anxious. It was hard to eat or sleep. I had a cough which caused tearing chest pain for about 3 months. I had some amazing teachers and made close friends. I treasured my experiences with my patients and was devoted to them, each one of them teaching me as I attempted to treat them. I had intense relationships with classmates who were incredibly gifted. I didn't kill myself, though I was tempted. I grew up. After finishing residency I learned more as I practiced with doctors who had different skill sets than mine.

Medical education was already changing when I finished. Students were starting to work with patients earlier in the process which gave them a context for learning the basic sciences. More schools were grading pass/fail. Work hours were being limited so students were better rested.

Now, I hear, students don't necessarily attend lectures. Some of them do but it is possible to view the lectures online, speeding up through the boring stuff, slowing or repeating the difficult stuff, viewing the lectures with a friend or friends so you can discuss the material. You can look things up while you are watching. You can go grab a cup of coffee if you are dozing off. You can ride a stationary bike or listen while driving. Different than my experience, for sure.

Dr. Emanuel imagines that lectures could be entirely available online and a student could access a lecture given by the "best" teacher. They could study from anywhere in the world! They could take competency tests and move on to clinical medicine when they know the basic sciences and whatever else they need to start taking care of patients. Lectures could be shorter, maybe just 15 minute mini-lectures to account for the fact that most people have trouble paying attention for an hour.

After testing and proving competency, students could progress to a training location where they would have all of their clinical experiences, finishing at the end of residency. That last bit would be the most hands-on education, requiring lots of one on one apprentice type teaching. Residency would end when further testing showed that a doctor was competent not only in treating and diagnosing disease but in ethics and human interactions.

It all sounds really interesting, potentially maybe better in some ways and a little dystopian. Or maybe a lot dystopian. Not to say that I am a fan of my medical school and residency experience as a whole, but we need to make sure we don't completely screw up the next generation of doctors by wrecking an already busted system.

The things that bother me are:

1. Relationships. One of the most transformative parts of medical school was my relationship with professors who I still respect and emulate decades later. Also my medical school colleagues were pretty amazing people and our stressful time together helped me learn how to forge strong friendships and accept help and support. 
2. "Best" teachers. There are so many different ways to teach classes and so many amazing teachers who bring their own stories and techniques to teaching. If we focus on the few best teachers and record their lectures and use those as our universal curriculum we will lose the wealth of all those other physician teachers. Plus there are many different views of physiology and disease processes, some of which seem wrong now and eventually will be proven right, but only if some students hear about them and apply their own minds to figuring things out. 
3. Medical schools bring people together and support clinical teaching and learning. Being educated online and offsite can have some definite benefits, especially making education available to more people and potentially reducing its cost. But the whole ecosystem that is a medical school performs a teaching function that can't be easily tested. Professors model behaviors. Students try things and get feedback that includes reactions of others as well as natural consequences. It is hard to know what we will lose if the structure of a medical school is not part of medical education.
4. It's really hard to give a good lecture to a computer screen. Even a lecture recorded in a live situation lacks some of the magic that comes when the teacher responds to the audience in real time. 
5. Cheating. If all progress is based on competency testing there will be a major focus on gaming that system. We risk promoting people who are nowhere near ready.
6. Online classes. It's so hard to get excited about these. Computer screens are always with us but interaction with screens is toxic. Often necessary, often beneficial but undeniably toxic to our brains.

I hope that people who will be involved in transforming medical education will think of these issues and will at least rigorously evaluate outcomes to make sure they aren't producing terrible doctors. I'm actually not sure that some of the changes in medical education over the last several decades haven't been responsible for a rise in mediocrity. It makes no sense to try to go back in time to educational techniques that were based on a world that no longer exists but I hope we go really slowly with this reimagination stuff and pay very close attention to what happens.