Future doctors will need to be expert and empathetic clinicians and scientists. They will also need to be imaginative thinkers with broad biomedical knowledge and the wisdom to shape health technologies, complex systems, public conversations, community organizations and health policy. To provide future doctors with this range of skills, medical education will need to be more efficient and effective.
With the passing anniversary of the Flexner report in 2010, medical educators have become increasingly interested in competency-based education that is flexible, outcome based, learner centric and deliberate practice rich.[1,2,3,4,5] Competencies emphasized throughout the literature have traditionally focused on medical knowledge, clinical skills, a spirit of inquiry and professionalism. Even then, most medical education is spent on developing biomedical knowledge and clinical skills due to vast inefficiencies. To maintain the pace of innovation new educational approaches are needed, not least so students can broaden their education with experience in bioinformatics, creative design and the humanities.
Joy Paul Gifford opined that thought is either convergent or divergent. A paradox of medical education is that evidence based medicine implies that when presented with similar information, clinicians should converge to similar conclusions, however the field of medicine needs divergent thinkers. Thinkers, who analyze, evaluate, create and challenge. By creating efficiencies in our approach to the convergent aspects of medical practice, we can save time and cognitive space for the divergent thinking that will revolutionize the practice of medicine. Or as Robert McCrae states: space for openness, artistry, curiosity and imagination.
Significant educational reform also has three major arguments in its favor: theoretical, anthropological, and socio-economic. These arguments place an emphasis on the learning process; one that takes advantage of current technology and addresses the needs of 21st century learners. When focused through the lens of a coherent learning model, the necessary changes to medical education become clear. The following sections address each argument in turn.
“We do not receive wisdom, we must discover it for ourselves, after a journey through the wilderness which no one else can make for us, which no one else can spare us.” — Marcel Proust
Educational theorists emerged in the 20th century utilizing data largely from K-12 studies and bolstered by growing fields of developmental psychology, social psychology and cognitive neuroscience to provide valuable contributions to our understanding of learning. Six broad schools offer a range of perspectives on effective education:
Behavioralists demonstrated that to a large extent tests determines behavior. They demonstrated that if educators build a maze, set up an expectation and reinforce behavior, subjects learn. Or as Comings stated in 2003, “The teacher’s role is to design an environment that elicits desired behavior toward meeting these goals and to extinguish undesirable behavior.” The behavioralists suggest to us that no matter how much we try to tell students what they should know, it will be the assessments that will most impact their actions. We can choose to fight this insight or we can embrace the idea that highly motivated students will act to efficiently overcome challenges, and shift our work as educators to provide students with daily exercises to optimize their learning.
Humanists identified the importance of emotion, meaning and sense making to learning and the educational culture. This represented a shift from learning as rational organization to include affective aspects that lead to personal growth and development. Carl Rodgers noted the importance of personal involvement, self-initiation through a sense of discovery, the pervasive feeling that the activity makes a difference, and the evaluation of the education by the learner leading to democratic involvement. In other words, humanists identify the essence of learning as the experience of meaning. Recent studies also affirm that as learners generate positive emotions, their scope of attention broadens and their critical thinking skills are enhanced. It is notable then that awe and wonder, with their dependence on a sense of scale, are hugely important to education in the humanistic and transformational frameworks of learning. By creating inspiring environments that support autonomy and community, we pay credence to this aspect of the learning experience.
Cognitivists unlocked the building blocks of how and why we remember. “The thinking person interprets sensations and gives meaning to the events that impinge upon his consciousness.” They noted that encoding and retrieval are separate systems whose rates are independent and that meaning and sense are criteria for long term storage. They demonstrated that encoding requires rote rehearsal, analysis, evaluation and elaboration and that the basic process we use to evaluate and transform information is meaning construction. This is achieved through observing, finding patterns, generalizing, forming conclusions and assessing those conclusions. Retrieval, on the other hand, is largely based on chunking information, which is a reflection of the expert’s knowledge base and previous work in encoding and transformation.
At the heart of these processes is repetition. Through repetition, words first take on sense then, potentially, meaning. Patterns are uncovered and sense making emerges. Meaning, however, is deeply personal. What connects a fact to an individual’s life experience or values is extremely difficult to predict. Through repetition, and in particular deliberate practice, learners have the greatest opportunity to find meaning in the knowledge and skills they must learn to become proficient professionals. If there is a key to the new education, it is the humble assertion that we need to provide students with many more opportunities for repetition and feedback. Learners will take care of the rest in unimaginable and profound ways.
Social Cognitivists call attention to the effect our peers and social environment have on our learning. Their research proves that both what and how we learn and in turn who we become is deeply influenced by our surroundings. As Bandura states, “People influence their environment, which in turn influence the way they behave.” There are powerful educational levers to be found in this idea. First, as we have learned from public health and the notion of blue zones, humans tend to behave similarly to their neighbors. Secondly, physical and digital architecture have a large role to play in cultivating optimized learning communities. Architects have looked deeply into the impact of this research and high tech workplaces continue to reflect the evolution of how they inspire thinking, imagination and wellness. Most medical education spaces are mixed use and the multiple missions of medical schools confound the impact of the learning architecture. With the single goal of optimizing learning, environment design becomes a simpler proposition. Spaces are needed that allow learners to comfortably practice their craft in close proximity to each other, have appropriate space for teamwork, have proper digital channels for online discourse and space for immersive simulation all while retaining autonomy.
Constructivists tell us that what we build physically, emotionally or intellectually most defines who we become. Piaget’s theory of how infants and children construct meaning at the intersection of experience and ideas has influenced higher education, in particular through the concept of active learning. In the last decade, consensus has formed around the idea of guided procedural skill acquisition whether it is physical or cognitive. How we construct teaches us. In a 2014 New York Times article, architect Thomas De Monchaux spoke of learning from legos. He points to the impact of serious play and the need for repeated creative action. Construction points to a joyous approach to learning that harkens back to childhood and engages aspects of the human soul often lost in the race for productivity.
Transformationalists speak to the particular moments we earn as educators, students and faculty alike. Transformational learning is “the process by which we transform our taken-for-granted frames of reference to make them more inclusive, discriminating, open, emotionally capable of change, and reflective so that they may generate beliefs and opinions that will prove more true or justified to guide action.” The basic processes we use to transform information are observation, pattern recognition, generalization, conclusion formation, and assessment. The basic process we use to transform ourselves is by being open, curious and empathetic to the realities our peers and mentors present. Only in environments that disrupt hierarchy to bring educators and students face to face at moments of openness will moments of transformation happen with increasing frequency. The educator can then go one step further, investing deeply in listening, and provide personalized insight when individuals are prepared, indeed eager, for change.
More recently, Anders Ericsson focused our understanding of learning theory through the experimental study of expertise. In simple terms, he demonstrated that expertise, the ability to intuitively and effectively apply broad ranging knowledge to the solution of problems, is gained through large amounts of deliberative practice. Deliberate practice is defined as repetitive engagement with appropriately scaffolded challenges with just-in-time feedback allowing for iterative improvement of the skill in question. A key aspect of deliberate practice is the analysis and fracturing of larger problems into constituent parts such that focused effort can be efficiently applied to each part.
Together, these theories and the resulting experimental work point to the need for a focus on individual and collaborative activities that are aligned with educational objectives, inspiring learning environments that take into consideration the student’s emotional and physical well being, and a system of continual expert-level feedback so that students learn from their experience.
Theory provides compelling arguments for a new education that will increase our ability to facilitate moments of transformation. This call is made more urgent by recent changes in learning culture accelerated by technology. Education must reflect the emergence of the internet, search engines, image and context recognition, social media and instant messaging.
Needs analysis — The internet context
In Learning in Adulthood, Merriam, Caffarella and Baumgartner state that educators would do well to consider the learner, that is who and where in culture, organization and society they reside; the learning process, that can be understood at the level of the brain, or the mind, or the social mind; and the cultural context, the milieu in which they learn.
The general approach to learning has fundamentally changed since the advent of the internet. We are now awash in data and digital natives have entered graduate school and beyond. The internet and social media allow for and encourage participatory learning where best sources are constantly being shared. The classroom is no longer an isolated monastery of information delivery but instead a starting point for discovery across the immense range of material available on the web.
Pew’s report on Networked Learners, already a decade old identified a number of trends in education: Learning is generally accepted as process to be learned, knowledge is considered subjective and provisional and organized “ecologically,” integratively, and interactively. Intelligence is based on networks that allow fast identification of meaningful data and students learn best doing and managing learning themselves.
A MacArthur Report from the same period identified the ascending importance of participatory culture. In such a culture affiliations, expressions, collaborative problem-solving and circulations are primary methods of exchange and meaning making. Affiliations are defined as memberships, formal and informal, in online communities centered around various forms of media. Expressions are the production of new creative forms, such as digital sampling and mashups. Collaborative problem-solving is working together in formal or informal teams to complete tasks, develop new knowledge or take part in alternative reality gaming. Lastly, circulations are the shaped flow of media such as podcasting or blogging.
In this cultural context, virtually all US medical students have settled on online question banks as the optimal method of study for the major board and licensing exams. Problem solving is clearly a prioritized method of learning. This is a clear market indicator of the type of activity deemed most efficient and effective by students. Little has been done to capture the data from this learning or extend this approach to collaborative problem solving or project based learning.
A concrete example of the power of online collaborative tools to teach and the market to instruct can be found in a case study of World of Warcraft. In this study we find a practice-based system’s incredible ability, however fanciful the context, to teach high level leadership skills. John Seely Brown, former Chief Scientist of Xerox Corporation and the director of its Palo Alto Research Center preferentially hires World of Warcraft guild leaders over other well qualified and credentialed candidates. He highlights World of Warcraft as one of the only education systems with data proving exponential learning in execution and leadership skills. The curves are due in large part to community information sharing, lucid dashboards for data review and communal practice based learning. In addition, the practice of playing games such as World of Warcraft encourage a questing disposition that equates learning, exploration and discovery with fun. According to Brown, WoW players are deeply interested in the bottom line — improving their play and leveling up — which initially requires individual practice but eventually requires increasing reliance on groups to sift through and provide meaningful new information and appropriate challenges.
Lastly, if we look the milieu in which doctors will find themselves in the near future we must consider the emergence of artificial intelligence as evidenced by IBM’s Watson and other deep learning platforms.[20,21] These accelerating approaches to artificial intelligence point to a time when the current skills of clinical reasoning and application of biomedical knowledge will be less important than wisdom and imagination.[22,23] The future doctor will need to be innovative and compassionate mediators between world of bioinformatics and the human patient. Sternberg suggests that education should balance practices that encourage wisdom and creativity with those that sharpen intelligence. As he describes it, “The wise person has a certain sagacity that is not necessarily found in the intelligent person. He or she listens to others, knows how to weigh advice, and can deal with a variety of different kinds of people….The wise individual is especially well able to make clear, sensible and fair judgments and is perceived to profit from the experiences of others and…learn from others’ mistakes, as well as from his or her own.”
So the market tells us to focus on practice, make it social and prepare for the time when imagination, creativity and innovation will become the most important intellectual currency.
Medical education in the U.S. costs too much. It limits students’ options and opportunities for global education. The staggering debt U.S. students take on to garner expertise in medicine significantly limits their perceived freedom to practice in ways that would help the most people or the most disadvantaged. In addition, the cost of medical education is prohibitive to many low resource areas around the world. This is not acceptable. Health care is an economic driver so in addition to curbing the global healthcare workforce, expensive education puts a break on local economies.
The Pew report, mentioned above, stated that an internet-enabled revolution in education has the opportunity to spread more opportunities. To this, I would add that innovation often comes from those with the least resources, the emergence of jazz in the poor south and mobile banking in Africa being two striking examples.[25,26] By spreading medical education to all corners of the globe, medicine will only benefit through enriched culture and unimagined innovation.
As an aside, by focusing on practice-based education and the intelligent use of technology, the resources and materials needed can be condensed and provided together with simple teacher training materials without the massive overhead currently necessary.
An equally pressing and ongoing issue in medical education is wellness. The incidence of depression may be as high as an astounding 25% of medical students, burnout is as high as 70% in some specialties and suicide is 40–300% higher than other professions. At the heart of these statistics is an educational system that condones untenable approaches to learning, living and being.
Precision Learning Environments
“If you want to build a ship, don’t drum up the men to gather wood, divide the work and give orders. Instead, teach them to yearn for the vast and endless sea.”
— Antoine de St. Exupéry
With the theoretical, need based and socio-economic arguments in place; arguing for educational change we are left with the question of how best to reimagine medical education. A simple model modernized for the adult education and the 21st century learner provides insight by serving as a filter for the practical use of theory and market research.
The Precision learning environment (PLE) is an organizational model that prioritizes the environment over teacher, student, and technology. When teachers teach, they are not the proximal cause of learning. They create an environment, rich with the words, images and emotion that a student may or may not choose or be able to learn from. When placed in context of the PLE model, it becomes clear that lectures and other classroom oriented didactic methods currently emphasized in medical education are only valuable as accessory educational formats. The PLE model demonstrates that by focusing on the environment and filling it with a rich and varied set of potential experiences, a much deeper and more effective learning experience can occur. Imagine the difference between listening to a detailed description of Yosemite Valley and spending a weekend hiking between the cliffs, waterfalls, trees and wildlife. Clearly the second experience would be far more impactful. The biomedical knowledge base is also an environment. Precision learning environments are adapted and optimized so learners can experience that environment, as they will. The teacher’s role is to optimize PLEs for practice-, project-, and performance-based learning. Sometimes this will be through inspirational lectures or feedback, sometimes through challenge creation, sometimes by connecting specific learners to each other. The PLE rewards exploration and discovery and provides data driven feedback and thus activates exponential acceleration of learning as suggested by theory and proven in sports and gaming.
Another metaphor is instructive. Musicians typically spends 80–90% of their time in the practice room preparing assiduously first for rehearsals that take place in rehearsal studios and then for performances that take place in concert halls. If we desire to have the largest impact on students we will utilize our resources, not on training teachers or on activities that take place in the rehearsal studio (or the academic equivalent, the classroom) but instead by developing the tools that allow the student to quickly assess his or her weaknesses in their “practice room” and improve those qualities. The practice room is the conceptual location where students study and must include training tools that facilitate efficient practice. The classroom can then be used much more effectively as a “rehearsal studio” to motivate and inspire students through project participation that allows students to work on communication and leadership skills while refining scientific reasoning. All of this is then in preparation for the concert hall — high fidelity simulation leading to real patient care — where students have the opportunity to apply the best of their knowledge and skills to patient care. The concert hall is the space to prove whether the dialectical skills, physical skills and wisdom students have gained during their practice has stuck and is stress-proof. When the data from these summative activities are folded back into the tools that facilitate learning in the practice room the education cycle is completed and the building blocks for an evidence based education are in place.
Salman Kahn has brought general attention to the effects on education when information delivery is moved online. The obvious questions then become: What do educators do with this reclaimed time? How do we change or adapt current learning spaces?
Two clear themes emerge from the literature regarding medical curriculum improvement: the need for an organizing model of learning and the need for rigorous data. Medical education needs to focus on improving learning itself and needs a coherent and comprehensive approach to continuous data collection and analysis to do so. This in turn requires assessment tools and curricular materials for students that are easily evaluated and adapted. To address this issue, what is proposed is a reimagining of medical education with a focus on learning environments optimized for automated individual practice-, project- and performance- based learning.
There is a clear historical precedent for this model: the Montessori Method. Dr. Maria Montessori, the first female medical student and physician in Italy has had a profound effect on grade school education and education theory. Although there is some variability in the application of her principles, the Association of Montessori International and the American Montessori Association state consider the following essential to education:
- Mixed age classrooms
- Student choice of activity from within a prescribed range of options
- Uninterrupted blocks of work time
- A constructivist or discovery model, where students learn concepts from working with materials, rather than by direct instruction
- Specialized educational materials developed by Montessori and her collaborators
- Freedom of movement within the classroom
- A trained Montessori teacher
This model provides an ideal framework in which to re-imagine medical school with four key additions required for adult learning and the modern learner:
1. Learning through autonomous high-volume, longitudinal deliberate practice
2. Globally networked learning studios
3. A data framework to facilitate instant data driven feedback and individualized training
4. Direct and meaningful patient care and community service activities
The grand paradox of medical education is that patients generate inspiration and meaning, but non-malfeasance says we must limit student responsibility during their early training. The practice room — rehearsal studio — concert hall model points to an era where early practice based learning, essentially low-fidelity simulation, builds steadily through high-fidelity simulation to patient care returning the information gleaned from the process to inform future practice. Medical Studios, the physical and online realization of precision learning environments will facilitate the activities needed for expert level practice, patient care and this natural progression.
Advanced educational environments and data driven training tools for individual and group practice allow for a constructivist approach to knowledge and skill transfer by fostering student dialogue, testing understanding, encouraging elaboration, and providing time for students to construct relationships between facts, concepts, narratives and reality.28,29 It facilitates formal and informal learning with a clear underpinning of data and shifts effort by faculty and students toward the practice itself.
This background has posited theoretical and practical arguments in favor of educational change and a model for understanding how theory and a deeper understanding of the learner, learning process and the cultural context should inform educational practice. This is the justification for the principles outlined in Part 1and Part 2 that should inform future education design. The arguments found here were the driving force behind the development of the precision learning environment model that in turn offers a vision for the transformation of education through rich learning environments for adults and practice based learning.
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