Does Medical Education Need a Revolution?
This week the Faculty of Medicine recognized some of its best educators at the 13th Annual Education Achievement Celebration. We wanted to get their thoughts on the future direction required for medical and health science education, so we asked: Does medical education need a revolution? If so, what would you change? While not all thought revolution was the right term, they all had thoughts on how the educational experience could evolve. Here are the responses.
Richard L. Horner
Professor of Medicine and Physiology
Sustained Excellence in Graduate Teaching and Mentorship Award
I am not sure that "revolution" is the right word - but I would say that education in the medical sciences can and should be upgraded to reflect the variety of learning styles of individuals and to take advantage of the variety of platforms to deliver and receive content. Personalized learning via an integrated platform encompassing online and on-demand content, case-based and theme-based approaches can tailor content that is responsive to an individual learner’s needs, background, and level of training. Online content should not replace face-to-face contact which is valued by both educators and learners. Increasing the depth and breadth of online and on-demand content further enables interprofessional and continuing education in the medical sciences.
Stephanie Nixon
Associate Professor of Physical Therapy
Early Career Excellence in Graduate Teaching and Mentorship Award
Yes. The revolution I am referring to has been underway for years in other fields (like gender students, indigenous studies, critical ethnic studies), but health professions education has been slow to catch up. The revolution is in response to the persistent and, in many cases, worsening inequities in health outcomes that are linked to structures of power, privilege and marginalization. Differential experiences of health, disability and mortality are well-established; the statistics are largely uncontroversial. Less clear, however, is what health care providers – and health professions education – should do to address these inequities. All too often, these inequities are understood as “just the way it is,” a natural occurrence. On the contrary, these inequities are man- and woman-made, and can be man and woman-unmade should we choose. Furthermore, there are behaviours within health professions education that not only ignore these issues, but actually reinforce and reproduce them. And so, to a revolution.
The biomedical and technical training in medicine, physiotherapy and other health fields is necessary, but it’s not sufficient. Health care providers also need training regarding the limits of biomedicine. Health care providers need to develop the skill to identify and critically analyze common assumptions in health care – because of the role that these taken-for-granted “truths” play in benefitting some at the expense of others. Here I am calling for students to be introduced to the ideas of ontology and epistemology, which are fields that examine ways of knowing and what gets to count as real. Linked with these insights is reflexivity – or insight regarding one’s social locations and how they have shaped the way one sees the world. This calls for more than just “cultural competence”; students need to develop a critical consciousness that enables them to better understand their own experiences of privilege and oppression and how these relate to their roles as health care providers. This may seem like a tall order, but it is one of the prerequisites for meaningfully tackling and dismantling the structures that consistently make some people healthy and others sick – and which, to my mind, is widely absent from many health care training programmes at present.
Alex Mihailidis
Associate Professor of Occupational Science & Occupational Therapy; Institute of Biomaterials & Biomedical Engineering
Continuing Excellence in Graduate Teaching and Mentorship Award
I feel that medical education definitely needs to change. We need to take greater care in teaching our students the importance of working collaboratively, whether this is our colleagues, or more importantly, the clients that we serve. Being able to work closely with others across sometimes difficult disciplinary boundaries requires a special set of skills that will only result in stronger and more invested clinicians, practitioners, educators, and researchers. Our goal must be to strive towards this type of transdisciplinary approach in everything that we do and teach.
Heather MacNeill
Assistant Professor of Psychiatry
Excellence in Community-Based Teaching (Community Hospital) Award
Our many health care successes have now led us into a new era of medicine — one in which people are living longer with multiple illnesses. Complex chronic illness (CCI) is now the norm, not the exception, yet we still continue to predominately teach and research evidence based medicine ‘siloed’ around single disease entities. Medical training primarily occurs in acute care centres, and learners ultimately become teachers in the areas they have had the most training and comfort level in.
The “medical education revolution” is already upon us — how will we respond to “the health care crisis” and treat CCI in an effective/ efficient way. How might technology help us in both learning from and caring for our patients (epatients, personalized medicine) and in our teaching (managing the information tsunami, IPE learning, and collaboration)? How will we transition from teaching a “find it a fix it” emphasis to a “manage and support” model?
Michael Pollanen
Associate Professor of Laboratory Medicine and Pathobiology
Excellence in Postgraduate Medical Education Award for Development and Innovation
PGME is in the middle of a revolution. The development of competency by design, the increased attention to objective-linked evaluation and emphasis on intrinsic core competencies represents a shift in approach akin to the problem-based learning revolution in undergraduate medical education. U of T is at forefront of all of these innovations. We are at the centre of the medical education universe.
Stacey Bernstein
Associate Professor of Paediatrics
Canadian Association for Medical Education Certificate of Merit
As I reflect on this question and think back to my own training at the University of Toronto, I realize a lot has changed. In the class of 9T2, most of our curriculum was lecture-based, and we only spent one year in Clinical Clerkship.
As educators, I don't think we would be doing our job well if we were not striving for excellence through continuous change as we adapt to the world around us that is transforming at warp speed. Our Medical School curriculum is in the midst of a revolution with an extensive pre-clerkship overhaul. We have longitudinal integrated clerkship (LIC) pilots at five hospital sites next year. The LIC is a relationship-based curriculum with the patient at the centre of care. So perhaps it is the hidden curriculum that is in the greatest need of a revolution. The hidden curriculum is a set of influences that function at the level of organizational structure and culture. It is the unintended curriculum that amongst other things, results in the erosion of empathy, idealism and ethics in our learners. It would be a major feat if we could uncover and reform the hidden curriculum.
Shirley Lee
Associate Professor of Family and Community Medicine
Helen P. Batty Award for Excellence and Achievement in Faculty Development
Medical education in my eyes IS undergoing a revolution already, as I see the shift in culture to the emphasis on learner-centered knowledge processes, and the excitement in the field being driven by medical educators in Canada who have the leadership, vision, passion and enthusiasm to embrace change. We are engaging globally to disseminate best practices and improve patient care, as well as keeping in mind the necessary balance of the humanities in medicine.
Mandy Lowe
Assistant Professor of Occupational Science and Occupational Therapy
Helen P. Batty Award for Excellence and Achievement in Faculty Development
We truly have a unique opportunity before us — to fundamentally change the way we educate and engage in learning ourselves. While we have made some gains moving towards more interprofessional approaches to learning in which learners across roles learn about, from and with one another to improve collaboration and health outcomes (adapted from WHO, 2010), we need to do even better as we strive to improve safety and quality through team-based learning and care. We must support all educators individually and in teams to build their own 'skills for teaching' including identifying, supporting and striving for excellence in teaching and scholarship. We ought to think carefully about how best to incorporate simulation and technology and align our approaches with best practices in these critical areas. And we need to fully engage clients/patients, families, communities and learners in new and better ways as critical partners in education. Finally, through relentlessly linking learning and care, we will strengthen both as learning is not distinct from care but an essential part of our core work — we are all teaching and we are all learning!
David Chan
Associate Professor of Neurology
W. T. Aikins Award for Excellence in Undergraduate Teaching
Absolutely, and I think this is already happening. As educators, we need to impart our future physicians with the skills that will allow them to be adaptive and responsive to future changes in health care, patient populations and societal needs.
Technology has become intricately tied with our lives. We need to use technology in medical education not simply because we have it at our disposal. We need to carefully identify specific curricular content where learning can be transformed by the use of technology.
Our assessments need to put a greater emphasis on portable and transferrable skills, such as clinical reasoning as well as application and synthesis of knowledge both within and across disciplines. There also needs to be a much tighter linkage between basic science and clinical content – one should always be able articulate explicitly how the inclusion of the former in the curriculum is critical to and/or enhances the understanding of the latter. Ideally, assessments should serve as another tool to enhance learning, and to enable this we need more frequent, formative testing with timely feedback.
While many aspects of medical education are changing constantly, one critical yet fundamental facet has stood the test of time – the doctor-patient relationship and the human aspects of medicine. Any reform of medical education still needs to embrace this as one of the key guiding principles in order to be successful.
John Teshima
Assistant Professor of Psychiatry
Helen P. Batty Award for Excellence and Achievement in Faculty Development
Medical education has often been guilty of not looking far enough outside of its own boundaries. Advances in educational practice and research can be well established for years in other fields before making inroads to medical education. Articles in medical education literature tend to primarily cite other medical education literature, even if key concepts or findings originated in other fields. Given that most human beings probably learn in similar ways, irrespective of field of study, medical education could better itself by looking more at what others have already been figuring out.
Medical education is also primarily taught by physicians. Beyond sending the unfortunate (and potentially inaccurate) hidden message that physicians know best, our trainees lose out a breadth of expertise and perspectives from other health professionals. Interprofessional education is beginning to address this problem to an extent, but there is also a role for non-physicians in many other teaching contexts. Involving patients as teachers is another underdeveloped option in many areas of medical education. Either partnered with physician teachers or even on their own, trained patient teachers could be contributing greatly to medical education.
So if I could make a change, I would help medical education look more beyond its own community.
Milan Gupta
Assistant Professor of Medicine
Colin Woolf Award for Excellence in Course Coordination
We all recognize that a career in medicine calls for lifelong learning. The revolution in medical education in fact began decades ago, and continues to this day. While didactic systems teaching has its virtues, patient or disease-centred education is now entrenched in most medical schools and post-graduate training programs. Continuing medical education also continues to evolve, with practical, patient-centred teaching and actionable key messages being the most effective techniques. More medical journal reading is now done online, where interactive audiovisual options enhance the traditional journal reading experience.
Fok-Han Leung
Assistant Professor of Family and Community Medicine
W. T. Aikins Award for Excellence in Undergraduate Teaching – Individual Teaching Performance (Small Group)
It ain’t broke… but we can still fix it. With the right mix of preceptors and professors, medical education has a proven track record of training competent and compassionate doctors. I believe we have a good foundation. This foundation is rooted in patient care, and since the doctor-patient relationship remains fundamentally unaltered, this foundation will remain solid. So how can we build on this foundation? I believe we can better train the next generation of physicians by learning from our neighbours and colleagues; we can focus on developing our international and interprofessional relationships. We can connect students in the medical teaching units, the pharmacy learning labs and the nursing simulation centres. Focused on patient care, we can be one large living educational laboratory, a medical education research network connected across faculties, universities and countries.
Lisa Andermann
Associate Professor of Psychiatry
Social Responsibility Award in Postgraduate Medical Education
My work in teaching cultural psychiatry and developing the advocacy curriculum for psychiatry residents has been shaped by my mentors in these fields as well as by my patients, students and colleagues, including my collaborator and co-award winner, Dr. Kenneth Fung. As the world becomes more complex — politically, economically, technologically — and with global patterns of migration, we need to know more about each other, not less. Learning how to bridge gaps in communication, understand the other's point of view, and attend to issues of cultural identity, acculturation, marginalization and understanding explanatory models of illness are part of our daily work as psychiatrists in a multicultural society. We also need to be aware of the impact of stigma and discrimination and how this can prevent people from seeking treatment and also have a significant impact on their social worlds. This was one of the motivations behind the development of Mindfest, a mental health awareness fair sponsored by Pillar 4 and aimed at the U of T community - students and faculty - as well as high schools and the general public. We are going into our 3rd year and continuing to grow with new partnerships and activities. I have learned a lot from this spirit of inclusivity.
Kymm Feldman
Assistant Professor of Family and Community Medicine
Canadian Association for Medical Education Certificate of Merit Award
Does medical education need a revolution? Yes! We are holding a think lab called 'The Breakthrough Conference' for just this reason. Students have changed. Consumption of medical care has changed. Access to high quality information has changed. How students learn needs to meet them where they are...which is not in the classroom necessarily. Much excellent work has gone into re-thinking medical education already and now we need to be open to really pushing it, questioning it, running with it. A revolution indeed.
Debbie Gurfinkel
Lecturer of Nutritional Sciences
Excellence in Undergraduate Teaching in Life Sciences Award
I hope you don't mind if I change the question to "Does life science education need a revolution?" as I don't teach medicine or medical students directly. I would like to see more emphasis on teaching students the process and methodologies of science, including their many strengths and limitations; students should understand how scientific knowledge is created. Too often we teach students the results of science because it is so much easier to do than explain how the results are obtained. Students should understand how science is done and have the opportunity to do some science themselves. By cultivating a better understanding of the scientific process, students will also be able to recognize good science and critique bad science. I don't believe that this requires a revolution, just outstanding teachers.
Adam Rosebrock
Assistant Professor of Molecular Genetics; Donnelly Centre for Cellular and Biomolecular Research
Excellence in Undergraduate Laboratory Teaching in Life Sciences
More than ever before, we need to prioritize ’teaching how to learn.’ I believe this is best accomplished by engaging students with hands-on learning. Modern medicine is evolving rapidly; our most successful graduates will be those who are able and self-motivated to engage in life-long learning. Factual information is available from a dizzying array of sources outside the lecture hall, from Google to Medscape to UpToDate. We frequently focus too heavily on memorization of current best practice or state-of-the-art, forgetting that students may have never been taught core concepts. I find that teaching scientific fundamentals through the lens of current knowledge provides students both the historical context and factual information needed to continue learning beyond the classroom.
In contrast to the move toward “à la carte” style course scheduling and content consumption, I believe that a more focused, better-integrated curriculum is necessary to maximize effective learning. At present, a widely cast net of prerequisites leads to classrooms full of students who must be repeatedly brought up a common level of background knowledge to the detriment of spending time teaching deeper understanding. Better coordination between individual instructors, course directors, and entire faculty can generate a streamlined curriculum where topics are introduced and intentionally reinforced and expanded upon among courses to great effect. Integrated curriculum are most effective when lectures are complemented with laboratory learning. Despite their operating costs and high faculty-student ratio, laboratory classes provide students with a bridge from theoretical to practical knowledge, build competency with techniques that students will use in professional practice, and enable real-time assessment of students’ grasp of learning objectives.
Competition from online courses and degree programs must incite us to leverage the advantages of the traditional classroom environment. While “virtual laboratories” and on-demand pre-recorded lectures are convenient for educator and student alike, they fail to deliver a cohesive learning experience and the critical transition from virtual to applied knowledge. "Content consumption" is frequently used to describe on-line delivery; successful students must be critically engaged, active participants in the learning process, whether in the lecture hall or laboratory. Well-integrated curricula including state-of-the-art lab courses demand more institutional resources, but provide students with a unique academic experience that is not easily replicated outside of the walls of the University.
Burton W. Knight
Assistant Professor of Endocrinology
Sustained Excellence in Community-Based Teaching Award
When asked to comment as to whether there is a need for revolution in medical education, I do not see that this need exists as from the time that I started medical school 45 years ago (nearly half a century and have some reluctance in admitting it), there has been either quiet revolution or evolution in in medical education in the following areas:
Teaching — from large hall didactic teaching to small group, problem solving sessions with an emphasis on self-learning incorporating the principles of adult education;
Decision-making — from opinion-based to evidence-based practice guidelines;
Information — I can remember sitting in the library on Sunday afternoons for hours doing literature searches with large volumes of Index Medicus and now using various electronic devices and search engines to obtain the information in seconds to minutes. I no longer need to carry a pocket reference notebook; and,
Curriculum — it now includes more emphasis on important subjects such as communication skills, bioethics, health economics, patient centered care, interdisciplinary care and education.
On reflection, changes in medical education have progressed over time from lecture based to patient centered care and the process is still ongoing. I consider these to be major advances in medical education. The challenges that I would see the for the future are 1) incorporating medical information and practice guidelines for individualized patient care and management; 2) that technologies should not exclude or diminish the importance of healthcare professional/patient contact and relationship; 3) to continue to have good role models as educators for learners; and, 4) incorporating all the new areas in the curriculum with emphasis on the teacher providing a holistic approach to medical care.
Ariel Shafro
Lecturer of Psychiatry
Excellence in Community-Based Teaching (Community Hospital) Award
Does medical education need a revolution? Sure, bring out the metaphorical pitchforks and torches! If there's any area that would require revolution in what I see, it would be in the process of testing and examinations. Over the past few years in which I've supervised medical students, I've accepted that there is absolutely no correlation (sometimes I almost wonder if there's a negative correlation) between a student's performance on their clinical rotation, and their performance on their final examination. I believe this likely flows from a few areas:
- The examinations often test minutiae that are of low importance in developing skills that would be beneficial in any area of medicine.
- The examinations don't reflect what many of my students can actually see (namely checklists of psychotherapy) in their community experience
- Information tested is often basic science or research-related that has little to no direct benefit for treating patients
- The oral examinations don't reward some of the skills that are necessary in real practice, namely the efficient use of open-ended questions, in favour of checklist recall
Much of the information does NOT need memorization, and could be accessed by phone/computer/other mnemonic devices that aren't available during the exam. I use a tablet PC daily, and have all the DSM criteria available to pull up at a moment's notice, in a way that doesn't negatively impact the patient interview (this would be more of an issue for less common diagnoses that even practicing psychiatrists would not likely remember perfectly)
Were it up to me, I'd trace the issue backwards, starting from a specific set of questions:
- What are the most important skills, attitudes, and knowledge that students should know about psychiatry for use OUTSIDE of psychiatry? Specifically as a practicing GP, though possibly as an internist, surgeon, or oncologist as well. Everything needed for a career in psychiatry can be taught during residency, while I believe we should be preparing non-psychiatrists for an empathic and competent approach to patients with psychiatric illness in any environment, as these are the places they're statistically more likely to encounter them.
- What is most likely to be retained beyond the first few days after they write their exams? Nobody is going to remember a checklist of CBT components a few days later, never mind a few years later on, so why bother asking them in the first place? This will clearly favour attitudes and skills over factual content knowledge.
- For content knowledge, how can we teach this more effectively to increase the likelihood of successful recall later? I still remember an approach to antibiotics, taught by a urologist of all people, during my clerkship. On internal medicine, the sheer amount of information is so massive that you NEED to organize your approach effectively. On psychiatry, we generally leave it up to our learners to develop these strategies, and I think with, some direction and creativity, we can do better.
Are the questions directly clinically relevant, particularly considering the practice environment of our future students? While knowing genetics, psychotherapy principles, and neuroanatomy is important for practicing psychiatrists (in varying degrees, depending on the nature of their practice), can we really afford to expand our scope of essential knowledge to include these when it's hard enough to find off-service residents that even remember how to start an antidepressant?
Somewhere along my training, it was impressed upon me that "process trumps content", and that we should focus on developing those skills that are necessary for practicing psychiatry, or any field of medicine, over the content that can always be easily read as desired. I hope that can start making its way into the undergraduate curriculum because as it stands, I think the way we do exams will sour our students' taste for psychiatry. My hope is that we can start testing them on what's truly important, and thus there doesn't have to be this parallel curriculum of "what you need to know for the exam" vs. "what is actually useful to know in practice", which is a constant struggle for me right now. I've barely even touched on how psychiatry and its practitioners and patients are often stigmatized by other specialties, and possibly trying to impart a more compassionate and informed attitude to our students. In meeting students sometimes years later, however, I’ve been consistently impressed that despite all that we can improve, they still turn out wonderfully.
Kenneth Fung
Associate Professor of Psychiatry
Social Responsibility Award in Postgraduate Medical Education
In addition to the latest medical technological advances in healthcare, technology is poised to revolutionize medical education itself. Use of simulation, telemedicine, webinars, flipped classroom, medical apps, and digital productivity tools can all enhance personal and collective learning experience and efficiency. At the same time, the critical role of physicians as empathic healers can never be neglected. A holistic bio-psycho-social-spiritual approach, cultural competence, and the CanMEDS competency framework will continue to revolutionize medical education, with the newer generations of physicians becoming ever more compassionate, patient-centered, and socially responsible. Further, interdisciplinary and interprofessional medical education will finally help breakdown silos in healthcare, fostering teamwork across specialties and allied health professionals and forging equitable collaborations with complementary healthcare providers, community organizations, family members, and patients as partners. These three drivers of excellence in medical education – high tech, high touch, and high team – will ultimately lead to better health outcomes, higher patient satisfaction, and a higher performing integrated healthcare system. The future of medication education is here.
