There is a large gap between expressed goals of higher education and the actual reality of training that goes on at the universities and medical schools in particular nation and worldwide.
These goals include, a widely shared vision of the physician includes being a knowledgeable and skilled evidence-based clinician, a strong communicator and team member, a compassionate and ethical practitioner, and an adept critical thinker.[i] It also requires, at the minimum, a practical understanding of research and research methods. More recently this vision has expanded to include the necessity for competence in bioinformatics, public health and complex systems innovation. While medical education has done a remarkable job over the past century in training competent and sometimes extraordinary physicians, significant opportunities for innovation in medical training remain to increase the number and impact of great doctors. The practice of and improvement cycle for medical education has become increasingly outdated, as new insights into learning and training as well as vast improvements in information technology fail to be adequately integrated into educational practice. This is especially notable in pre- and inter-service training.
Recommended educational initiatives to improve education include standardization of learning outcomes, individualization of the learning process, integration of formal knowledge and clinical experience, development of habits of inquiry and innovation and a focus on professional identity formation.[ii]
The question is, how to achieve these aims that encompass such a vast array of skills and qualities? How do we educate the ideal physician through the proposed initiatives? How do we do this efficiently and effectively?
The solution, a practical approach to applying these initiatives to education, is in the application of a coherent set of design principles. The following design principles are the logical conclusion then to 20th century learning theory, extensive needs finding and clearly established socioeconomic arguments as outlined in Reasons for the New Education. They will align the shared vision of the medical professional and our education system.The principles are (see an expanded outline):
0. Understand the learner
1. Set clear expectations for education
2. Maximize learner autonomy
3. Focus on high-volume deliberate practice
4. Provide continuous, fine-grained assessment and evaluation
5. Network education and learning
6. Build inspiring learning environments and experiences
7. Invest in education design, innovation and research
There are a number of expected outcomes that will result from adhering to these design principles in the areas of expertise, culture, innovation and the learning environment:
Expertise. First and foremost, the design principles set out a framework for improving expertise across the array of skills needed by the future doctor to positively impact health and wellness in the U.S. and worldwide. Second, the principles will increase educational efficiency. Lastly, they will reap huge rewards for education science. Creating a practice based system with an underlying data and analytical structure is the equivalent of providing education scientists with a telescope to probe the universe of the learning mind.
Vibrant Culture. Culture that does not renew itself becomes stagnant. An education based on the principles outlined above will enliven and reinvigorate medical culture by preserving more time for humanism, imagination, compassion and deep reasoning on the part of teachers and students. It will inspire confidence to create system change and motivate students to commit to each other as the optimal way to learn. It will allow medicine to continue to broaden its approach to admission with newfound confidence in the power of its training. The integration of students from a full range of educational and socioeconomic backgrounds facilitated by this approach will propel innovation and redirect healthcare and science to dynamically meet future challenges.
Wellness. It is no longer acceptable that physicians and other healthcare workers sacrifice their own health and wellness in the service of others, if for no other reason than it is neither sustainable nor effective as a long-term vision. The need for an immersive experience during residency is not an excuse for indentured servitude. An education based on the principles outlined above will insure a sustainable approach to healthcare and medical innovation. The practice of learning becomes the practice of medicine becomes a life practice. Stated goals of wellness and health are only viable insofar as they are practiced on a daily basis. We lead by example.
Innovation. From Mozart to Einstein, from Johnson to Osler, it is clear that the heart of scientific discovery and medical innovation comes through a well primed imagination given time to wander through inner and outer landscapes. If medicine is to continue to progress and solve the standing and future issues surrounding chronic disease, health and wellness, physicians will need to commit to this essentially artistic process.[iii] This will require preserving more time for reflective thought, impossible in the current rushed life of the clinical physician. The design principles outline a process that will train imaginative thinkers who will prize time to exercise the skills they have developed and will innovate systems to provide this time.
Environment. The realization of education in light of these principles will likely take the form of a network of studio-like training facilities on college campuses worldwide that facilitate cognitive and physical training while current educational infrastructure will continue to facilitate the research and community building mission of universities. This network of inspiring yet low-cost medical studios realized at participating universities will facilitate high volume-practice of evidence-based clinical reasoning and management while saving time for imaginative thinking so important to the next generation of innovative and compassionate health care providers.
A deeper dive
0. Understand the learner
While this set of design principles is based on existing research and a large investment in empathetic needs finding, it bears repeating as a principle that education fails when we do not continually work to understand the learner, from day to day and generation to generation. It is imperative to understand in general and in detail the learner’s values, motivations, and inspirations. It is also necessary to understand how each learner learns and modify the education to match. By definition, when a learner fails, the education has failed. Given the rate of change of technology and culture in today’s world, it is evident that the need to understand our learner will be the primary and ongoing challenge to education.
1. Set clear expectations for education
From business to sports, technology to finance, the expectation for constant and quantifiable improvement has led to astounding growth and achievement. Medical education has worked to define goals and expectations but lacking rigorous metrics to evaluate the effectiveness of education itself, has failed to achieve this type of continuous improvement. That medicine itself continues to progress is largely due to advances in science driven by smart admission policies that guarantee strong student performance. In order for clinical medicine and indeed health care in general to accelerate its value to society, a clear expectation of continuous improvement in educational outcomes is needed. Such expectations will counterpoint AAMC’s Entrustable Professional Activities(EPAs), which clarifies the skills student are expected to have upon entering residency and is similar in spirit to their 5 year roadmap Optimizing Graduate Medical Education.[iv] These expectations will require dedicated resources independent from clinical, research and infrastructure expenditures.
The expectation of educational improvement then must be based on rigorous data that demonstrates what and how students are learning. Simply, if the foundational content is similar from year to year, then students should be learning it in less time and scoring higher on final summative exams. To put it even more plainly, students should learn more, faster, at lower cost and with greater inspiration.
While the complexity of medicine, including the breadth of knowledge and nuance of clinical reasoning and management, is staggering, it is not in-and-of itself incompatible with a rigorous approach to data driven student assessment and educational evaluation. Only lack of resources and will deter schools from the challenge. Until we take on such assessment, which is central to deliberate practice and the acquisition of expertise, we cannot meaningfully improve.
With the ever-expanding base of biomedical knowledge, efficient education is now a necessity. Utilizing experts to deliver basic information is not only a poor use of their time but prevents them from providing much more systemic benefit through the curation and creation of problem-based learning environments. By making the acquisition of basic knowledge and skills an automated and efficient process medical education can reserve this time for innovative pursuits. The only route to innovation is through the practice of innovation by teacher and student.
This implies new roles that emerge as a byproduct of the other principles. If we focus on practice based learning, provide intelligent networks for students and faculty, and design inspiring physical and online environments, students and faculty will naturally assume roles more conducive to optimized learning and innovative thinking.
However, as change will likely take place in fits and starts with partial implementation, a direct engagement with new roles will more readily facilitate educational change. These roles will at once be more intellectually stimulating, difficult and personal. Teachers will spend less time lecturing and more time creating enticing learning environments, and more specifically curating cases, challenges and problems along with appropriately edited answer keys. This new role as curator will be facilitated by the learning metrics collected continuously by educational technology that highlights individual and community learning trends. At higher levels, faculty will be responsible for tracking and updating the assessment and evaluation data structure to facilitate continuous quality improvement.
The practice-based approach will allow faculty to focus on providing inspiration, mentorship and coaching, finally supported by rich data available to educators in real time. In addition, most of evaluation will be removed from the job profile of the teacher. Training and performance will be well tracked and the teacher can focus simply on helping each student improve. Now, like in their work as doctors, they can employ data to influence coaching needs, providing just-in-time assistance uniquely individualized to the particular strengths and weaknesses of each student. Training in sports and games is now rich in data, the new education will follow suit.
Faculty must be empowered to act like explorers, curators, and team coaches. They will be assessment developers and game designers. They will search for images, diagrams and narratives that inspire and clarify. And they will continue, as always, to model the role future doctors will assume. Importantly, in the new education, the role of teacher and student will be at once more creative and data centric, thus aligning the education of medicine with the practice of medicine itself.
As Fenwick noted in 2003 in the Transformational Learning process[v]: “The mentor serves as guide, cheerleader, challenger, and supporter during the learning process. The teacher/mentor challenges students to examine their conceptions of self and the world to formulate new, more developed perspectives. And gets the learners involved in a community of practice.”
Similarly to the new role for faculty that is at once more autonomous, systemic and personal, students will also take on a new role, richer with responsibility and activity. Students will train on a daily basis and be much more responsible for their peers. Their role will overlap more concretely and usefully with faculty and staff as they help evolve the problems/games/challenges they themselves and future students will play. They will practice, train, explore, discover and innovate both within the curriculum and by influencing the curriculum. They will be constantly assessing their peers through formal peer review processes and through informal feedback facilitated by the networked, problem-based environment. They will be central to the positive iteration of a learning environment that will be flexible enough for them to mold it to their needs year-to-year while rigorously improving its overall effectiveness.
In the new education, students will be collaborating much more often while being assessed on the quality of their collaboration. Such teamwork is an absolutely vital part of patient care and expertise in teamwork should be expected. And in order for students to develop their imagination and creativity they need time to wonder and dream. This is not something that can be squeezed into the last 15 minutes of the day it should be practiced, regularly and with appropriate feedback. Lastly, like faculty, they will be constantly modeling behavior for their peers through a system that supports, validates and requires their democratic participation in the educational community.
In addition to being more efficient and inspirational, the same education should cost less each year, making room for further education. Eventually, it should simply be low cost. Having a low-cost education will free doctors to pursue their individual ethical visions and help those most in need.
Expectations should be both very high and extremely clear. They should detail aspects of knowledge and skills across all the fields of expertise required for future physicians and explicit metrics should be created to assess progress in these fields.
2. Maximize learner autonomy
This is an obvious concept with research backing up common sense and demonstrating that adult learning, motivation, happiness, and curiosity all improve with autonomy. Dr. Maria Montessori realized this and immediately saw the results when she maximized autonomy for her grade school students. While she provided more strict limits to that autonomy, as learners’ age, there is less need for socialization by the educator. Medical school admissions, board exams, residency positions and eventual job search provide more than enough pressure and accountability for learners. It is long past time that we trust adult learners to optimize their approach and support them in that endeavor. Educators should simply provide the materials for exploration and then track and coach students as they progress.
3. Focus on high-volume deliberate practice
Education has traditionally focused its resources and efforts on teacher training and classroom materials. The new education will need to focus on practice and the tools that facilitate practice. The second design principle implies that education can be improved by shifting focus to where the majority of learning takes place, between the ears of the learner, most often when he or she is away from teachers and classrooms. Learning science has shown that learning takes place as students practice the cognitive skills they need. This is where education is equivalent to training. Educators must therefore shift effort from developing didactics to creating challenges, as the new curriculum will need a large volume of problems to practice. The volume of information and skills required by medicine makes it difficult for the novice to know where their practice is the weakest and little in our current form of education gives them the constant feedback required to move the needle on this aspect of learning. Lajoi suggests that “dynamic assessment, is ‘defined as a moment-by-moment assessment of learners during problem solving so that feedback can be provided in the context of the activity.”[vi]
As stated in The Medical Studio: “We can now create educational efficiencies by moving beyond the laborious, expert-led, synchronous, classroom approach to learning to an education based on individual deliberate practice and collaborative project based learning that take place in a technology enabled studio environment. Curricula should utilize a large volume of digital cases, problems, projects and skill simulations that closely mirror the actual cognitive and procedural aspects of healthcare practice. This frees students to learn at their own pace while engaging the critical thinking skills and individual accountability necessary for their fluid integration into ever evolving healthcare systems.
While this novel approach shares aspects of both case-based and problem-based learning models, it is radically different in implementation and execution. By utilizing technology to provide instant feedback and individualized challenges in a studio environment, students participate in constant individual practice, develop a growth mindset and derive benefit from the variety of their peer’s expertise and experience while interacting with experts when they have the most to benefit.[vii] This shifts and automates repetitive teaching tasks.
The practicality of this approach is in no way antithetical to the development of broad knowledge and critical thinking skills required by the physician-scientist. In fact, this model will inspire a much deeper curiosity and desire to explore, qualities central to scientific thinking. It achieves this by focusing on solving increasingly difficult real-world and theoretical challenges, giving students, at once, more time and autonomy, and providing more consistent individualized qualitative and quantitative feedback.”
Anders Ericsson’s research on building expertise through deliberate practice is both well known and well accepted.[viii] What is needed is proper application of his theory to learning in academic and professional fields. What is needed are training metrics and incentive systems to encourage individual deliberate practice.
By focusing on practice, students not only develop the requisite cognitive skills to practice medicine from day one, they begin to immediately and concurrently develop intuition for the natural history of disease and the steps to its management, something that is taught sequentially and discontinuously in current medical education. Like music, learning itself is a mixed intellectual and intuitive process only partially captured in the idea of illness scripts. Through volume practice that allows the mind to see the pattern despite variation in detail, intuition will grow intertwined with knowledge allowing each to support and advance the other.
There is currently little data or feedback on the accrual of knowledge and cognitive skill that takes place day to day. This can be rectified by offering students a system that pairs problem solving with immediate feedback, suggestions for optimum training and automated scheduling of future challenges. The problems can take a number of forms but all have key elements of difficulty stratification, built-in and detailed assessment metrics aligned with clearly defined core skills and a large enough volume to facilitate pattern recognition.
The ideal practice based curriculum will include an interconnected list of cases that allow students to assess expertise across a range of cognitive skills applied to a variety of patient presentations. A student would take on a virtual patient, answer questions and receive points in the various categories depending on the nature of the question. As the student progresses, cases can become more subtle or obscure, requiring deeper cognitive skill or knowledge. Challenges can also take the form of projects that can facilitate teamwork or physical challenges to test procedural skills, all of which can be assessed with expert defined metrics.
Practice can take on ever more fidelity to patient care and thus increase the performative aspect of medicine. Performance is practice that takes place under pressure and will tend to crystalize learning and motivate future practice. Performance is the capstone event in a practice-based curriculum that gives feedback both to the student and to the educator, informing both as to how to adapt the training plan. The value of the performance in this regard is dependent on the level of detail in the data that is returned.
If students are regularly given the opportunity to practice, complete projects and perform, they will optimize their learning to achieve across whatever metrics educators choose to collect. To date exams have been blunt instruments for assessing learning but with continuous data collection and a commitment to setting specific objectives, we can accelerate learning across disciplines. Or as Lajoie advocates we can “make the expertise trajectory visible to learners through models of expertise, feedback, or examples that promote the active transfer of knowledge and self-monitoring.”[ix]
4. Provide continuous fine-grained assessment and evaluation
As hinted at in the prior section, medical education has been inhibited by the lack of a coherent assessment structure including learning analytics that track expertise across the skills and knowledge required of a physician.
In professional athletic training, short-, medium-, and long-term training plans are created based on initial assessment of athletic performance. These plans include subtle periodization of activity to insure optimal progression across the range of skills and fitness necessary for top performance. Metrics encompassing multiple types of muscular activity and various aspects of the athlete’s performance are tracked on a daily basis. While game-time performance is to some extent variable, most performance is largely predictable based on training. The value of training can then be evaluated, comparing performance to the training plan and execution. It is long past time that the same approach used to develop the cognitive and physical skills necessary to become an excellent clinician. The exact nature of the skills and the best metrics to define the skill will be a matter of continuing research, however it is clear that there is a body of knowledge and a set of cognitive, teamwork, communication and physical skills that we can begin to track. Each time a students attempt to solve a problem alone or together with their peers, we have a unique opportunity to understand how they learn.
With such a system of continuous assessment in place, final exams become useful to assess the quality of the education, not the student. How a student will do when managing the specific constellation of signs and symptoms embodied in the biopsychosocial aspects of a particular patient should be largely known based on their track record of practice. The surprise when they perform outside of expectations will then be the driver for changes to the individual student’s training plan or the metrics we choose to collect. These metrics will provide a scientific basis for evaluating and improving medical education.
Continuous assessment will generate timesaving as students can be redirected in their studies according to their particular constellation of strengths and weaknesses. And with the time saved, new knowledge and skills, important to the next generation of physicians can be acquired. Expertise can be proven through the detailed analysis of action within the educational community.
Current problem-based curricula suffer from a low volume of adequately scaffolded cases and challenges and even more concerning, a system to provide individualized feedback to students based on their daily performance. A single case, exam or quiz is not nearly enough to plot learning trajectory and give guidance.
While professional athletes can afford personal trainers, clearly expert level tutoring for each and every medical student is not economically viable unless the training system is automated. This will require a set of metrics and an approach to their yearly revision based on evaluation of student progress compared to their performance in the patient care setting.
Ideally these metrics will be shaped at a national level, with involvement from a wide range of institutions and governing bodies informed both by their clinical expertise and the data emerging from the system. By instituting fine-grained metrics at a national level faculty and students can collaborate across and between schools while the benefiting from a large study population for effective evaluation. The most exciting aspect of these metrics is the opportunity to connect specific aspects of learner expertise to patient outcomes. With the large and specific data set recommended, the opportunity for an evidence-based education becomes a possibility.
This convergence around a set of fine-grained metrics amounts to a ‘learning contract’, where expectations and assessment become well aligned. When students are able to track their progress on a daily basis towards the expertise required of them, education will fundamentally change.
To make this idea more concrete, a set of initial metrics (from a much longer necessary list) is suggested and aligned with AAMC’s EPAs:
· To create a differential for common signs and symptoms or combinations of signs, symptoms and laboratory findings.
· To apply knowledge from epidemiology to help rank the probability of the illnesses on this differential
· To interpret laboratory findings in the context of the patient’s presentation
· To suggest steps in management
Each problem in a case will have points related to one or more of these categories and students will gain points in the various categories as they progress through problems and cases. As they practice, their particular pattern of strengths and weaknesses will become apparent to themselves and their mentors.
To assess scientific reasoning or teamwork, students would complete projects where they would evaluate methodologies, assess statistical methods, draw conclusions, engage in peer review and again be given scores based on answers to specific questions. Wherever possible, validated instruments would be used in assessment.[x] For instance, to assess teamwork existing tools such as teamSTEPPS or measures of psychological safety could be utilized or adapted.[xi]
Students have always played school as a game and medical students are particularly good players, doing work to score optimally on exams or other assessments and then using remaining time to take on inspirational projects. If we create better metrics and connect them to future learning opportunities, students will play with abandon and enjoy the wonder and awe of unlocking fundamental understanding of how the body functions, how it breaks down and what we as medical professionals can do to bring it and our communities back to health. They will transition naturally to becoming lifelong learners that is a key quality of a great physician.
The initial metrics will inevitably be flawed and this will highlight weaknesses in our education. This improving data structure will define the future of medical education and allow for causative links to be established between education and patient care outcomes setting the stage for an evidence based education. Only when we can track a student’s daily learning process and connect that data to outcomes will medical education start to take on the rigor of other scientific fields.
In a more general sense, this represents a much larger commitment to listening. Great teachers are the best listeners. It requires huge and difficult commitment to holding back knowledge in order to preserve time for understanding the student. With dynamic and valid data structures, teachers are given the tools to listen in a new and exciting way. We have the microscope and telescope to see more clearly into the cell and the sky. We need detailed analytical instruments to hear what our learning minds are telling us.
5. Network education and learning: Share values, resources and community
Infrastructure has a huge influence on a country’s prosperity. Highways, power and light, water and communication systems are the backbone of national health. In the 21st century there is no industry that is not taking advantage of existing networks and in particular the networks facilitated by the Internet. Innovation and profitability are largely connected to how well and coherently they do so. Higher education has yet to build or take advantage of a well-designed shared digital infrastructure. One reason for the slow adoption are university structures themselves that have become local knowledge fiefdoms that are dependent on publication in competitive journals and yearly conferences for information transfer.
Education has always been a resource scarce field so there is little option but to recycle and share content. Not to do so is an incredible waste of expert level talent, which in turn inhibits innovation. By creating and sharing online content we can save significant expert time for more important endeavors. Medical education needs a coherent national infrastructure for student and faculty communication, collaboration and continuous assessment.
In addition, students and teachers should be connected within and between universities, not by the silo of the course, but by what they are learning moment to moment. What is happening informally already; the use of texting, Facebook messaging, Snapchat, Skype, Google chats and internet forums should be adopted and facilitated. But this is just a starting place. These tools must be optimized to allow for instant connectivity between students around the world working on the same topic.
While lateral sharing of information will hugely improve education, we also require the consensus efforts of our governing bodies to help define the characteristics required of our students and the metrics most likely to reflect those characteristics. While much of the higher level objectives are in place, this requires a commitment to the nuts and bolts of data tracking and how learning metrics correlate to patient outcomes and physician performance.
And education needs more than shared content and data. If the new education, with its emphasis on practice based learning, continuous assessment and data, eradicates the course and most of the current hierarchical methods of training, it will require a new level of democratic participation by all participants. Students, faculty, staff and administration will need to commit to education in the same manner they do to health care. Education should not be a big ticket item to be bought and passively consumed. Learning, by definition, is an active process and this participation in the process of education will only improve feelings of citizenship, socialization, and commitment to the future communities in which students participate.
6. Build inspiring learning environments and experiences
The penultimate principle for the new education is a unifying one. By focusing on the educational environment as an organizing principle for education above and beyond teaching, participants or technologies, we can create spaces optimized for intellectual and emotional growth and achievement. We must create intellectual environments, physical rooms and digital spaces not generically appropriate for a vague education but precisely optimized for individual and community healthcare learning. They must also, together with the experience design, provide emotional variety and engender compassion, seriousness, fun, wonder and awe. At the core of this principle is the idea that educators, whether they lecture or make a game, create intellectual, physical and digital spaces in which learners explore, discover and construct in order to learn. If the environment is one that inspires, that motivates, that instructs, the teacher has succeeded. Creating environments, like those achieved by great authors, filmmakers and game designers, is the most powerful lever educators have to influence students. Well-designed learning environments, by definition offer learners a large degree of informed autonomy over their experience, which inspires responsibility, engagement and passion. Lecturing forces students into a single sequential experience of knowledge and concept that is at odds with the highly dependent and interconnected nature of biomedical knowledge. The concept of the environment allows the learner to follow their instinct while providing enough feedback to inform best practice.
Four examples are instructive, each from a different media. In music, students have intimate practice rooms with mirrors, personal recording systems and example recordings. When they practice they have the sound of their instrument to reflect upon. In architecture, carefully crafted studios provide well-lit spaces, generally with high ceilings, to encourage large scale thinking while individuals work in close proximity to their peers. In climbing, specialized gyms offer a selection of climbs rated by difficulty that allow students to stratify their ability and work at an optimal level for their experience and strength. In tabletop role-playing games, players explore imaginative worlds described through storytelling and take on challenges as a team. They gain experience in both adapting to the imagined environment and to their peers while optimizing their characters persona, through specific metrics, to achieve defined ends. To be an effective player and enjoy the game they must sustain the imaginative image and the fantasy world and of their dynamically changing characters in it.
In each of these examples, the environment inspires, while providing students with feedback, allowing them to deliberate on their performance and make improvements or train more effectively. This allows a large part of their growth to be optimized without oversight and gives educators a rich guide to student’s inner experience though reviewing their journey.
There has been little innovation in the physical design of academic medical school’s learning spaces. However, space, and its interaction with sound and light, matter, especially when practicing or studying. Windows and proper ergonomics inspire open thinking. Sound reverberates in vastly different ways through different geometries affecting mood and activity levels. A well-designed space need not be costly to be effective. A simple but well thought out space can engender wonder and a commitment to serious practice. The space must allow individuals to study without distraction while also providing incentive for community practice and teamwork. Research has clearly demonstrated the positive impact of natural surroundings on human health and wellness. To ignore such evidence is at odds with medicine’s mission as we try to inspire future practitioners of medicine to be models of health and wellness.
If the new education is to be practice-based, data rich, individualized, autonomous and communitarian, we need spaces that support these qualities. What is needed is meaningful and beautiful architectural, visual, diagrammatic and narrative design to inspire, and savvy activity design to motivate. Inspiration can be drawn from studio design, game design and theater design. Particular emphasis will need to be paid to images, which often can present information in much more lucid and organized fashion than text. Collecting and presenting beautiful and thoughtful charts, diagrams, animations, photographs and videos will prove an invaluable service to medical education.
As stated before, learning can be unpacked into three types of activities: practice-based learning, project-based learning, and performance based learning. In practice-based learning, knowledge retention and clinical reasoning is best achieved through deliberate practice that is adapted to the individual’s needs. This requires quiet and uncluttered online and physical environments. In project-based learning, critical thinking, professional identity formation, teamwork and communication skills are best achieved through content creation, peer review and faculty feedback. This requires adaptive and safe spaces that encourage discussion, critique, failure and iteration.
Performance-based learning, where the skills learned in practice- and project-based learning are placed under pressure in real or simulated environments, requires careful staging in preparation for patient care. Special care needs to be paid in the design simulation environments balancing cost and fidelity. Simple theatrical practices to “set the stage” can make a huge difference in the feeling of reality to a simulation and need not be expensive. A projected image, a beeping heart monitor, a single bed, an IV or ultrasound can provide the setting for dress rehearsals and provide vital feedback prior to patient care. Practice of critical, clinical and team thinking skills through simulation and clinical experience improves timely application of learned knowledge and skills, especially when they take place in appropriate environments.
Digital spaces must likewise offer the appropriate setting for deliberative practice. A simple interface, devoid of clutter and containing the necessary practice, communication and feedback tools tuned to the care of virtual patients will focus the learner on gaining the requisite expertise, while removing the digital noise so distracting to concentrated thought.
Even lecture spaces deserve better treatment. A lecture should be a time of wonder. There should be laser focus on the presenter with data taking a back seat. A power 15 minutes talk in a dark room with a single spot and a great speaker will do so much more to inspire and motivate an intelligent group of students than 100 poorly produced powerpoint lectures. The details and data can always be acquired and considered later.
The efficiencies created by automated coaching and the environmental model can be leveraged to learn new skills including project development, peer review, public health interventions, complex system analysis, bioinformatics, ethics, teamwork, and community organization. The application of these skills to real world problems in raw, project appropriate environments, primed for making, will make for inspiring experiences.
If learning environments become the focus, the practice of teaching will be one of environmental design and the practice of learning one of exploration and discovery. The promise is manifold and the potential for unexpected improvements to learning and the experience of learning and teaching is unlimited as students and teachers step into a common space.
7. Invest in education design, innovation and research
Investment in education independent of other criteria such as clinical responsibilities and research has always been limited. Flexner made impassioned appeals for educational funding in the early 20th century and the educational needs are even more urgent now. The introduction of practice based learning and deep data and analytics will create a new cycle of investment as the impact of education on the bottom lines of patient care and community health becomes clear. Education research will take on new value and for the first time make provable claims as to the economic impact of training.
In order for investment to have the greatest impact, it needs a simple mission: to increase value to the learner. By now, it should be clear that this implies investment in precision learning environments, problems, simulation and most importantly, the underlying infrastructure to the new education: data. With data and resources in place, we can train more thoughtful, imaginative, creative and wise doctors and in the end, these will be the qualities of upmost value in modern health care work.
By conscientiously applying the design principles outlined here, an evidence-based and inspirational medical education will emerge that more effectively achieves the ideals laid out in the Carnegie Reports of 1910 and 2010 and reiterated by the AAMC and ACGME. Doing so will require investment in new spaces, content and technology. The outcome will be an education that is at once more inspiring, efficient and lower in cost. It will connect students around the world and lower barriers to entry, unburdening students from the massive debt loads here in the US and opening up medical education to new populations all while providing an approach that will cultivate the responsibility, accountability, compassion, wonder, awe and passion with which most medical student approach this great profession.
[i] Irby, D. M., Cooke, M., & O’Brien, B. C. (2010). Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Academic Medicine : Journal of the Association of American Medical Colleges, 85(2), 220–227.
[ii] Cooke, M., Irby, D. M., & O’Brien, B. C. (2010). Educating physicians: a call for reform of medical school and residency (Vol. 16). John Wiley & Sons.
[iii] Beveridge, W. (1950). The art of scientific investigation. The Art of Scientific Investigation. Retrieved fromhttp://www.cabdirect.org/abstracts/19522203234.html
[iv] Association of American Medical Colleges. (2013). Core Entrustable Professional Activities for Entering Residency. MedEdPORTAL, 1–114.
[v] Fenwick, T. J. (2003). Learning through experience: Troubling orthodoxies and intersecting questions.
[vi] Lajoie, S. P., & Lesgold, A. M. (1992). Dynamic Assessment of Proficiency for Solving Procedural Knowledge Tasks. Educational Psychologist, 27(3), 365–384. doi:10.1207/s15326985ep2703_6
[vii] Dweck, C. (2006). Mindset: The new psychology of success. Random House LLC.
[viii] Ericsson, K. A., Krampe, R. T., & Tesch-Römer, C. (1993). The role of deliberate practice in the acquisition of expert performance. Psychological Review, 100(3), 363.
[ix] Lajoie, S. (2003). Transitions and trajectories for studies of expertise. Educational Researcher.
[x] Lurie, S. J., Schultz, S. H., & Lamanna, G. (2011). Assessing teamwork: a reliable five-question survey. Family Medicine, 43(10), 731–4.
[xi] Henriksen, Kerm and Battles, James B and Keyes, Margaret A and Grady, Mary L and King, Heidi B and Battles, James and Baker, David P and Alonso, Alexander and Salas, Eduardo and Webster, J. and others. (2008, August 1). TeamSTEPPSTM: Team Strategies and Tools to Enhance Performance and Patient Safety. Agency for Healthcare Research and Quality (US).