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The Evolution of Medical Education

by Monte Troutman, DO – Publications Committee

This piece was originally published in the January/February issue of the Tarrant County Physician. You can read find the full magazine here.

I can brag on myself as I have been involved with medical education for over 40 years now. Thirty-seven of those years were spent working as an assistant and then an associate professor of medicine at the Texas College of Osteopathic Medicine (TCOM) within the University of North Texas Health Science Center. I was the first full-time gastroenterologist there. I left private practice in Dayton, Ohio, where I was adjunct faculty at the Ohio University College of Osteopathic Medicine. I wanted to be more involved in medical education than that position offered. So why am I telling you all this? So you know that I have been around a long time and have seen a lot of changes, including monumental ones in medical education, from the classroom to clinical bedside clerkships. 

UNTHSC developed an Academy of Medical Educators where physicians, other health care providers, and basic scientists at TCOM have learned and discussed the theories and principles of medical education including Bloom’s educational approach and Miller’s framework for assessing clinical competence. 

After we learned the fundamentals, we now concentrate on other aspects of medical education. One of the of most significant changes that has transformed how we educate is that we no longer “lecture.” Indeed, it is now considered a four-letter word—lecturing is seen as passive learning.  Also gone are reading assignments from textbooks. Other forms of education now rule the roost. This includes online education and interactive forms of learning. 

So, what is so wrong with textbooks? About 10 years ago, I read a letter to the editor in the New England Journal of Medicine, where two second-year UCLA medical students calculated the total number of pages assigned by instructors for one semester. A staggering 10,000 pages were assigned and were fair game when testing occurred at the end of the semester. Too much? Yes!

A recent Google search stated the doubling of medical technology in 1950 was 50 years, in 1980 seven years, in 2010 three and a half years, and in 2019 one and a half years. Now in 2020 it is 73 days; not even three months. I recently told this to a fourth-year medical student on my service and as his eyes widened, he exclaimed, “That’s scary!” So, to revisit what is wrong with textbooks, here it is: The editors work with other experts to write a designated chapter, all work is edited and corrected, it is then published, printed, distributed, and purchased, etc., etc. This whole process takes years. So how many times has medical technology doubled in that time frame? Educators still refer to textbooks, but as references, not as primary education material.

A man walks into a bar in New Orleans and asks for a Corona and three hurricanes. The bartender hands him the bill—$20.20. Yes, the COVID-19 pandemic has changed things, possibly permanently. Virtual medical education is the current modus operandi. Zoom, WebEx, Skype, and, to name a few, are the classrooms today.  Right now, learning clinical skills is generally virtual. Inconceivable but true—not hands on but virtual patients. Not entirely new, just brought to the forefront due to the pandemic.     

Over the past several years, the lecture (that four-letter word again) hall has been sparsely filled unless attendance is mandatory, as some medical schools still do require, or if an in-person quiz is on the schedule. Before attendance began to drop, medical educators made the classroom an interactive session and the iClicker was used to respond to questions. However, with Power Point presentations now online before the lecture is given, and voice over with the Power Point, why go to the lecture hall? Pull up the Power Point whenever you want, play it at 1.5 to 1.8 speed, and listen to it twice. The thought is that the classroom is wasted time, and you avoid being called on in class. 

There is still in-person training. I teach in the second year, which includes small group sessions called Clinical Reasoning Modules (CRMs). In the CRMs, about eight to 10 students are presented with clinical cases by a moderator who leads the discussion on history, physical, labs, imaging, etc. The model used is a version of clinical reasoning called a “mind map,” and it stresses differentials and necessary testing and imaging. Grading is based on participation. As the “clinical expert,” I rotate to all the small groups and answer questions.  This is where I get to meet students I have never seen before. 

So, if there are no textbooks or lectures, what do the students do to prepare or to learn? Good question! Instead of scheduled lecture time, regular time is scheduled during their day to “study.” Faculty prepares Directed Student Activities (DSAs).  The DSAs include society guidelines, videos, online sites like Up To Date and more. Here textbooks are listed, usually as reference rather than test material. As you can imagine, the students are very resourceful and tell me about sites they find on their own that support their learning process.  The list I have been informed about and use to refine my DSAs are Baby Robbins, Pathoma, First Aide, Sketchy Medicine, Get Body Smart, Picnomics, and Hardin MD. As you can imagine, the time spent by faculty to screen all these sites is overwhelming. Since our curriculum is problem-based, symptoms or problems are the topics of our DSAs. Since I am a gastroenterologist, my topics are abnormal liver chemistries (not called LFTs anymore), nausea and vomiting, dysphagia, GI bleeding, constipation, diarrhea, and so forth.  Can you imagine the time needed to condense these topics into DSAs that are current and learnable using this format?

 I have been around a long time and seen a lot of changes, including monumental ones in medical education, from the classroom to clinical bedside clerkships. 

To worsen the situation, clinical clerkships have been adversely affected by the pandemic. Many institutions banned medical students from direct patient contact, and in some instances, from entry into hospitals or surgery centers. Virtual patients were used to teach clinical skills devoid of in-person contact or interviewing. When will they get to see patients in person and learn bedside and in-office clinical skills?  Who knows with the recent COVID-19 surge. Some have learned telehealth clinical care, which in some cases may be here to stay. Recent legal issues about student participation in clinical care have also started to cloud the problem. How will all this impact future clinical skills? 

So, all these issues in medical education will indeed have an impact on health care. Medical educators have their work cut out for them in the new learning environment compounded by a seemingly never-ending pandemic. Not only are medical students educated to pass boards and clinical competencies, but to become lifelong learners. They must learn without DSAs and with doubling of medical technology every several months. When do they learn cost restraints, physical exam, and other competencies? 

I know that this essay is called the Last Word, but this is hardly the last word on this topic. Hold on to your hats—this is a new world. Who knows what the new normal will be? As for me, the Last Word is that knowledge can be communicated, but not wisdom.

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