Dr. Chris Nickson recently asked, if a Martian landed on Earth and looked at how we do medical education, what would she think?
Could it really be true that so many dedicated, brilliant people with the same objectives could be doing exactly the same thing at the same time without sharing their resources? … That they could put so much work put into teaching sessions that so few actually attend? The Martian would think to herself, why don’t these educators find a way to share resources? Why don’t they make video and audio recordings so that learners can review them when it suits their hectic schedules and learn asynchronously… Perhaps students could even do all the didactic stuff before the teaching session even begins, then learn actively through discussion and simulation in a flipped classroom?
Nickson makes a powerful set of arguments in favor of “FOAM“—free, open-access meducation. It’s as simple as it sounds: you’ve probably heard of Khan Academy‘s great work “flipping the classroom” so that rote learning takes place at home, and classroom time is saved for collaborative problem-solving and application—FOAM extends that model to med school.
What would we go to class for? Be creative. I know one of my most helpful small-group experiences was reading EKGs with a practicing cardiologist. We could do the same with radiographs, with pathology slides, with metabolic panels. I also know that there’s no substitute for cadaver dissection, shadowing physicians, and practicing clinical skills–so we’d still be showing up for those valuable experiences. Finally, in this post at least, I’m only thinking about FOAMing the preclinical curriculum; the following two years on the wards can’t be replaced by online videos.
I won’t rehash the arguments in favor of asynchronous learning per se—read Nickson’s post or this NEJM article for more. Or go to a med school lecture hall and count the heads in there; you’ll see that asynchronous learning is already happening (9 a.m. starts + videorecorded lectures = asynchrony by default). I’m more interested in what would happen if we took this idea to its fullest potential. And I can think of several huge wins we’d gain, but only if we really flip it all the way:
Win #1: Standardized quality. We’ve all been there—you’re in class with a lecturer who doesn’t want to be there, and to be honest, you don’t want to either. Some teachers will always be more effective than others. Why does every school have to reinvent the wheel for every single course? By giving every student the best of the best lectures, we’d be able to learn better, and hopefully care for patients better. Not to mention that this is already happening–many students rely on sources like Pathoma (even paying out of pocket) for highly effective teaching they may be lacking in class.
Win #2: Individualized goals. What if we took “flipped” education as a way to go deeper in what you’re more interested in? In the first and second years of med school, most people don’t have their specialties decided, but many have an inkling. Becoming familiar with each is an important part of the first two years, but becoming an expert in all is impossible. We all have to choose one, but the preclinical years are decidedly one-size-fits-all. With more flexibility, students interested in surgery could go deeper into surgical approaches and anatomy. Students interested in primary care could learn about behavioral change and prevention. And this isn’t inconsistent with Win #2, standardizing quality–everyone gets the best of the best, but they get a chance to focus more on what speaks to them.
Win #3: Saving time. Dr. Ezekiel Emanuel thinks we could shave 30% off the length of medical training; preclinical training is a good place to start. Three US schools are already rolling out ways to get an MD in three years instead of four by streamlining preclinical education. And if you’ve got the drive to cram twenty months of preclinical education into twelve, why shouldn’t you? Like everyone else, you’ll still have licensing exams and clinical rotations to test your mastery–but if you can learn what you need in half the time, you should be allowed to try (but don’t say I didn’t warn you).
Win #4: That money thing. With time spent in med school comes money. A huge draw of the new three-year tracks is the amount they’d save students in tuition and other expenses–at least $60,000 a head. The amount is nothing minor, but it could mean more for our entire healthcare system–since many students cite debt as the reason they choose lucrative specialties, shortening training and cutting debt could make it easier for students to choose primary care. And if schools spent less time and money reinventing the wheel for each course, instead sharing what they’ve already developed, I have to believe it’d take something out of their expenses. (I poked around for numbers to quantify the cost of developing lectures, but unfortunately it doesn’t seem like schools are investigating this. Go figure.)
Seductive as they may be, there are a few powerful forces keeping these wins from taking root. One is the culture of academia as a whole, in which professors must teach in order to be “productive” scholars–even if they don’t want to, or if they’re not the best at it. If they don’t, it’d be harder for them to ascend the academic ranks. But I’d argue that if their interests are in research, they should be rewarded for doing research instead of lecturing unwillingly at our expense. Educational efficacy should trump dated scholarly norms. The accreditation standards for US schools don’t even include in-person lecturing: all the more reason to experiment a little.
Now, I’m not trying to suggest that putting a few lectures online will cure all that ails medical education. But I am asking for us to, at least hypothetically, reimagine preclinical training from the ground up. The resources are all out there, but schools need to acknowledge rather than resist them. Doing so could create more time for us to learn the art of medicine—doctorish things like patient interaction, diagnostic reasoning, and exam skills—while freeing us to learn the science of medicine the way we do best.