Redefining our ‘medieval’ medical education
In medieval times, an instructor would stand affront the lecture hall, reading aloud from an original text while students diligently scribed notes. Centuries later, despite the commonplace use of PowerPoint, my medical education proceeded in largely the same fashion.
The first half of medical school consisted of mostly in-person didactic learning while the last two years involved an apprenticeship model in which I delivered direct patient care, spending about a month in each medical specialty.
Our medical culture and practices are deeply rooted in tradition, with the norms of medical education continuing relatively undisturbed for the last century – until COVID-19. Massive disruption has occurred that has forced the medical education community to re-examine our practices. To better understand the future of medical education, I spoke to an international group of experts from Canada, the United States and the United Kingdom.
Times of Change
In the early days of the pandemic, the rapidly evolving situation demanded swift change within medical education. Dr. Roger Wong, Vice Dean of Education, Faculty of Medicine at the University of British Columbia (UBC), “remember(s) vividly … (the) weekend of March 13, 14, 15” in which the strategic decision was made “in three days” to transition UBC to remote teaching and online learning to continue delivering high-quality education while staying safe. This is remarkable given the historical context of stagnation in adopting virtual learning technology within higher education around the world in the preceding decades.
In the United Kingdom, Dr. Simon Fleming, a Trauma and Orthopedic Resident and Vice Chair of the Academy Trainee Doctors’ Group, was one of the first education faculty members recruited to the National Health Service Nightingale Hospital London, an emergency 4,000 bed hospital built in an urban conference center. Fleming recalled “we demonstrated that in seven to 10 days we (could) go from an idea to a functioning critical care hospital.”
These sweeping changes had a dramatic impact on the mindset of medical educators worldwide. Dr. Martin Pusic, a Pediatric Emergency Physician and Associate Professor at Harvard Medical School, described how the “usual change friction … evaporated” when both individuals and institutions were compelled to change. In particular, he described how the pandemic catalyzed adoption of “competency-based” practices in American medical education, a sluggish area of reform over the past five to 10 years. While educators previously recognized the value of skill-based milestones over time-based requirements to determine advancement in stages of training, deciding upon the ideal competency milestones had been an ongoing challenge.
During COVID-19, redeployments to support the pandemic response disrupted required rotations for many trainees to the extent that national licencing bodies in the United States determined that competency and graduation decisions would be made by individual programs in a holistic assessment rather than traditional time-focused metrics.
Although this was a departure from previously centralized competency requirements, Pusic noted that “what competence looks like for an anatomical pathologist … looks (nothing) like (competence) for an orthopedic surgeon,” and that “each of our groups have assessment systems and are confident that the people they graduate are good at what they do.” Ultimately, “COVID may propel us over the threshold” to competency-based education, he told the New England Journal of Medicine.
In their final year of training, medical trainees typically complete a series of certification exams that allow for independent practice. However, Dr. Esther Kim, a Radiology Resident at the University of Manitoba and current President of Resident Doctors of Canada (RDoC), described significant safety concerns in gathering trainees amidst the pandemic to sit their exams, noting that “RDoC received over 750 emails from (concerned) residents” across Canada. Due to RDoC’s advocacy, Canadian certifying bodies postponed the spring certifying exams until this fall and additionally implemented on online option for the exams in an unprecedented manner.
However, recognizing the uncertain future of in-person exams, one medical school in the U.K. conducted high stakes examinations for final‐year medical students in a remote access and open-book fashion. The school noted that this approach presents a viable alternative particularly when assessing higher-level competencies such as knowledge synthesis rather than factual recall. Kim noted that the future of high stakes licencing exams is “the question that everyone’s asking” and is “a moving target (to which) we have to … adjust accordingly.”
Reaching an equilibrium
Dr. Brian Wong, a General Internist and Director of the Centre for Quality Improvement and Patient Safety at the University of Toronto, described how the rapid adoption of virtual learning has come with both opportunities and challenges. Online learning allows for “asynchronous … longitudinal exposure to a topic,” he noted, while increasing accessibility for both speakers and learners. However, its implementation has come with growing pains, such as difficulties engaging learners, that have required a “quality improvement mindset” to continually adapt educational practices.
Although the rate of change has increased during the pandemic, Roger Wong said he believes that medical education will eventually “hit a new equilibrium” in which the ideal balance of online and in-person learning will be determined. Pusic described COVID-19 as an unexpected “natural experiment” in which medical education suddenly was shifted “100 per cent online” in a way that was previously “never explored.” However, both Roger Wong and Pusic note that ultimately the ideal balance of virtual and face-to-face learning is a blended model, incorporating elements of both modalities.
Rethinking medical education
While Fleming’s role at Nightingale came with the natural challenges of “building … medical education infrastructure from the ground up,” he also described the creative benefits of working with a “blank slate.” The Nightingale team was able to build its idealized institutional culture that Fleming described as “a real culture of learning and growth” with a “flattened hierarchy.” For instance, a novel bedside learning coordinator role was established to engage with frontline providers to identify areas for improvement. The hospital also held daily clinical forums in which all staff could attend to provide recommendations, with Fleming noting “everyone was there … not just the big wigs … and you were welcome to attend and add to it.”
Brian Wong also viewed COVID-19 as an opportunity to re-examine medical education with a blank slate. He cautioned that there may be a tendency to view the pandemic as temporary and simply use virtual technology to “recreate in-person learning online.” However, like Fleming, he views the disruption as a chance to consider “unique opportunities and ways of teaching and learning that are not possible in person” such as bringing in guest speakers from a distance or creating a true “flipped classroom” in which learners view content ahead of time with in-person time reserved for discussion. He postulated, “if we had started from scratch, (with) no residency program to speak of and we had virtual technology at our disposal, (how would we) create learning experiences for residents? How would we actually design those experiences differently?”
Along the same lines, Roger Wong theorized that we will be entering a “post-COVID era” in medical education given the significant “paradigm shift” brought forth by the pandemic.
A catalyst for change?
A discourse has emerged that the seemingly omnipresent impact of this virus has catalyzed change for “every country, every sector and every walk of life.” The tremendous loss during these times has indeed forced us to look inwards and reflect upon our world. In the medical education community, we have adopted practices that were once deemed not possible or not ready, such as virtual learning and competency-based advancement, and have accordingly narrowed our definition of impossible.
In our interview, Fleming noted “we are living history.” After reflection, I would take this a step further and say that we are writing history – the days of medieval education are long behind us and we have the opportunity to redefine medical education as we know it.