MEDICAL EDUCATION, THE INTERNET AND OPENNESS, IS IT REALLY A GOOD THING?

Medicine is a constantly evolving field, with treatments and guidelines to manage and prevent diseases changing constantly. One of the fundamental duties of every doctor is to “make the care of your patient your first concern” and “be competent and keep your professional knowledge and skills up to date”. The only way to achieve this is by being open. My chosen medical speciality is infectious diseases which deals with the management of microbial infections. Microbes are constantly evolving new ways to resist antimicrobials, thus there is a constant need to develop new anti-microbials and update guidelines to decide when and in what circumstances novel antimicrobials should be used to delay the development of resistance against antimicrobials. Key to this process is openly sharing research and guidelines, and collaboration among individuals involved in this field.

In my first blog for the OKHE 1 assignment I explored how encouraging students and medics to be more open and share their own experiences of professionalism, their struggles and successes in their career can be liberating, insightful and helpful to younger trainees, but being too open could come with a price to pay in the future, and in some ways may not always be such a good idea. Similar issues to the one in my field of infectious diseases are seen in all fields of medicine, and is why openness has to be a priority of medical education. Thus in this blog I want to explore the theme of openness further in medical education.

In February 2018 I was involved in giving introductory talks to the new cohort of students starting on the postgraduate course I teach on. In preparation I had prepared a reading list for students based on resources that had helped me 6 to 11 years ago studying on a similar course. A second year students was giving a talk to the new cohort about revision techniques. She told them not to ‘waste their money on textbooks, everything they need to know is free online’. Having spent £700 on medical textbooks between 2006 and 2011 on my own undergraduate degree this statement came as shock, and made me reflect how much education, particularly in the forum of medicine has evolved. It also made me appreciate that if myself as a teacher wants to make a difference, and really do something positive in medical education it’s essential I become more aware of the open material out there, how to access it and then contribute to it. After all I’m a teacher, isn’t it my job I do this?

There are a mass of websites publishing material specifically for medical students. Freely available online textbooks, and videos on sites such as Youtube could even negate the need for some classroom session. National and international guidelines for diagnosing and managing a range of conditions, and plotting disease trends are also widely available. Knowledge sharing in medicine is helpful, but it is a necessity to ensure the highest and safest standard of patient care. Sharing of research about a topic is essential to create best practice guidelines, and ensuring all material about one topic is open prevents the repetition of research.

A study in January 2019 revealed that 92% of medical students rely on online teaching videos and 90.6% of medical students rely on online question banks for learning. The reason so many depend on online resources can likely be explained by how a new generation of students have grown up to use and become dependent on smartphones, and become socialised to reach for their smartphones and search online for information when presented with a task. The new generation of students are particularly responsive to visual information such as videos which reflects how the newer generation communicates and interact with each other and the world today.

I was first introduced the idea of the “generation z” in another colleagues OKHE 1 assignment titled, “About-face: Openness and Lecture Capture”. Generation z are people who are born later than 1995, and due to influences of social media and modern day culture are more likely to communicate and make sense of things with images and videos, rather than text, the generation z thrive on interacting with people, and see using social apps as the norm. To ensure the best possible care is given to patients, I have a responsibility as a medical educator to make sure teaching material is open, but, it’s also my responsibility to ensure material is understandable by our target audience. Is generating freely available online textbooks a wasted endeavour if generation z are more likely to make sense of images and so many medical students rely on online teaching videos. Additionally studies show “generation z” are moving away from traditional social media apps like Facebook and are hungry to use platforms which encourage face-to-face communication. We need to ensure that the information we create is not only open, but is in the correct place where our desired audience are likely to find it, and that the format information is presented in relates to students. The new generation are more likely to respond to formats such as videos and vblogging.

This poses more many problems though. Personally I feel using a textbook and the process of reading allows a more thorough analysis of the subject. It allows one to go back and re-read information, allows someone to read at their own pace and so gives more time for an individual to think and process what is being read. This allows the reader to really think and decipher what the text is communicating and whether they agree or disagree with what they are reading. Videos and images make this more difficult and we loose some of the detail via this format. It’s also easier for individuals to be coerced by an attractive, likeable visual display or a charismatic, likeable and convincing speaker. Is there a chance in transforming to a more visual way of learning we are compromising quality and increasing the chance of coercion?

There’s also the task of re-training academics and teachers who for years have been taught more traditional methods of learning to now present information and deliver teaching materials in a more animated, visual and video fashion which is appealing to younger students.

There are anxieties among academics and professionals that openness “put’s one out there, front and centre, and that this may expose one to criticism. Any mistake in what was said or an opinion that is controversial many years after it was originally said could come back to haunt oneself. So, perhaps the safest thing to do is be less open. Anxiety will probably be higher in creating the more personal and visual resources that the newer generation expect such as vblogging and videos. I have been involved in creating clinical video resources for medical trainees, which were uploaded to Youtube. The idea of having my face on a learning resource so everyone to recognise me felt more daunting, and the comments I received felt more personal compared to comments received from open written resources I had published. I was even surprised by how individuals felt the need to comment on my dress sense and hair style, rather than genuine academic debate about the videos. Are the risks of more criticisms, including more personal critiques something we need to accept will happen in this era of openness since the results are maximum impact of our teaching. Or do there need to be more ground rules in openness. Linking your face or voice to a resource makes it a lot more personal and one is more likely to take any comments or criticism a lot more personal.

There’s also the issue of information privilege, an issue which one usually associates with more resource deplete institutions, where WiFi may not be as readily available and institutions cannot pay for the resources needed to access up to date literature beyond a pay wall. Yet even at modern Russell group university like the University of Manchester (UoM) is information privilege an issue? Students at UoM have access to a wealth of textbooks and journals, yet some of the most up to date literature on managing illnesses, particularly on rare conditions is not accessible through a standard UoM account.

It is also important to remember that being a medic is a practical skill which requires the opportunity to see patients with specific medical signs and by observing how experts speak and examine patients. The increasing number of medical students and students from other healthcare specialities means there is increasing competition to see patients during hospital placements, which reduces the opportunities to experience patients with real medical signs or shadowing healthcare professionals. Therefore, many students rely on clinical videos and images online, through various sites to perfect these skills. However, there are patient confidentiality issues which prevent the upload of such material to be openly used, and access to such resources usually comes at a cost, that many students cannot afford. The issue of ‘information privilege’ for those that have the extra money to access these resources will therefore prevent the best treatment of patients. As educators it’s our duty to try and mitigate this.

I primarily teach on the physician associate programme at UoM. A large percentage of our students live far from the university campus and have other commitments such as part-time jobs and caring commitments, additionally students on this programme spend half of the academic year on clinical placement. The huge variety of open material online makes it a lot easier for our students to access learning material. Being able to provide open online resources allows the programme to deliver distance learning resources, so students continue to learn when they are out of the classroom away from campus, and at times that are convenient for them. The programme has developed a number of online materials, but it is impossible to do this for all topics, and we regularly signpost online material for students to use. However, it can be challenging to find correct resources which reflect the specific learning needs of the curriculum at UoM, and we therefore sometimes find our curriculum and learning outcomes are dictated by the resources available.

As well as the learning resources we suggest, students tend to ‘shop around’ themselves for the resources that suite the unique way they learn. It’s encouraging that students have the flexibility to choose, but it can be easy for students to get side tracked and focus on things they feel are helping, when in reality they may not be that important or at the extreme could be delivering incorrect information. As an educator trying to guide students through the myriad of open resources available is difficult to police.

Students are often over fixated on assessments. After utilising so much money, time and effort into a course it’s necessary for them to succeed in assessments to evidence the investments they have put into studying. I expect most other educators did the same, but fixating too much on assessments can distract one away from what information that is actually important to be a successful practitioner. The individuals who do the best at assessments don’t always make the best practitioners. In view of student rated importance on assessment material, many educators publish assessment practice material (some freely open, others requiring a payment which prevents those students who cannot afford having this advantage). With the wealth of open assessment material it makes it increasingly difficult for educators to create novel assessment resources not already available. With all the available assessment material (most written by educators) there’s also the concern that students invest too much time on this and not on material that will make them better practitioners. The majority of medical programmes assess students with multiple choice questions such as MCQs. Students will put a tremendous amount of effort into preparing for them. MCQs test factual knowledge and don’t assess whether one is actually competent in practicing as a medic. Students can be too fixated on practicing MCQs without realising that this will prepare them very little for the real world, and actually reading a medical blog on medical ethics or watching a video on medical leadership will be a lot more useful in their career than just doing MCQs. This highlights the trap students can go down in focussing on resources they believe to be helpful to them, and not considering what would be beneficial in the long-term. Thus highlighting the importance of signposting students to the right resources to use.

Learning facts about illnesses, or watching teaching videos is only one aspect of medicine. It’s imperative during university training that students develop a sense of ‘professionalism’ and other skills that cannot be learnt in a classroom, reading journals and textbooks, nor by watching teaching videos. This includes communication skills, learning what the right thing to do is in challenging situations, or developing and performing leadership characteristics. Is this something we can teach? I reflected on this in the OKHE 1 blog ‘What’s yours is mine, what’s mine is yours’ which suggested that the most important people you learn from are your teachers, including professionalism and appropriate behaviours. Additionally studies have shown that the best way for students to develop these skills is by observing ‘role models’ ie. other junior doctors in clinical setting or being actively involved in simulations where the student role plays difficult scenarios with an actor. Is there a way in which being open can help with developing behavioural and professionalism skills? Perhaps it’s time for academics to introduce more open material on online platforms which are developed by their ‘role models’ such as qualified medics in the form of videos or blogging to share experiences and help develop professionalisms in trainees. Yet there is also the issue of the hidden curriculum, this is what students learn from outside the ‘official curriculum’ ie. the effects of behaviours and opinions observed among peers and healthcare professionals. If the attitude of this ‘hidden curriculum’ are negative values, all the work originally done by the educators can be negated. There’s also the concerns among Doctors and other healthcare staff of the repercussions of ‘putting themselves out their’ and the consequences of admitting to mistakes, conflicts or poor behaviours that may have occurred. A sensitive topic that was discussed in my original OKHE 1 assignment.

Openness and barrier free dissemination of information in medical education is not only helpful to learning, but is pivotal to achieve the best effective care for patients (the top duty of any medic). Openness is not without it’s downside, but in my opinion the pro’s outweigh the con’s. It’s something myself and other medical educators are going to have to get used to if we are to be of any use for the way in which the future generations learn and interact with the world. With the wealth of knowledge already out there, it’s important we understand and can use this environment in order to guide our students to the right resources, and start creating our own open resources that reach out to students, at the same time being mindful not to replicate what is already out there. For myself this has required some re-training and research into which resources students relate to best and the laws governing what I should and should not put out there so as not to breach confidentiality of patients and protect my own integrity. To further develop the open resources I have already created, I plan to create more videos from the ones I have been involved in previously, which simulate difficult interactions that could be encountered during clinical situations, and place these on YouTube. This visual way of learning will hopefully bring to life the ethical dilemmas and professionalism values they read or study about, and to be able to see what approaches can be taken to manage these situations.