Three Ways Medical Education Could Better Serve the Modern Learner

Moving Towards Modern Medical Education and Training — Part 8


Alfred Lord Tennyson said, “Knowledge comes but wisdom lingers.” (1) Cumulative knowledge coupled to productive experiences will eventually create wisdom in a receptive individual, system or culture.

Wisely directed medical decision-making is what our patients expect and deserve. Unfiltered knowledge, such as that widely available on the Internet, can create chaos. Filtered and focused knowledge, from that abundant resource that enlarges every day in medicine, is foundational to building wisdom in our profession. How then can these interdependent qualities, knowledge and wisdom be preserved, improved and transferred for the benefit of our patients?

Historically, storytelling has transferred wisdom from generation to generation. Ruth Benedict highlights in her book “Patterns of Culture” (2), as well as in her other works, that cultural relativism helps determine what ethics and value systems will be passed down as we tell our stories. In our culture, adequate, affordable and first-rate medical care is highly esteemed. The exponentially growing knowledge and wisdom in the profession of medicine, therefore, requires precise and rapidly evolving means of presenting these stories to both providers and recipients of medical care.

Older cultures passed wisdom on by way of learned storytellers who instructed new aspirants as their protégés. Ancient writing techniques, followed by books then became the way of preserving knowledge and wisdom. 20th Century technical advances led some storytellers to film and then television, followed of course with the development of IT-based solutions for knowledge and information transfer.

Medicine for the most part stayed with books during this technological evolution, until recently. But now books in medicine are largely obsolete unless such resources are available electronically and constantly updated. IT tools have emerged that could allow us to deliver knowledge and transfer wisdom, in a timely manner and rapidly updatable; these tools can serve us as essentially dynamic, evolving libraries.

The intentionally disruptive writings of Dr. Lawrence Weed in the 1960’s on the Problem Oriented Medical Record as a decision making, treatment and educational tool, spawned his corollary ideas on knowledge couplers. Dr. Weed’s then somewhat iconoclastic writings and practices foreshadowed the potential of modern IT systems to filter, focus and transmit knowledge and wisdom for medical care providers at all levels.(3–7)

Many others have followed Dr. Weed’s brilliant lead and have integrated his theories, to some extent, both in the clinical and educational missions. Some of his principal ideas have been codified in federal regulations by way of the Affordable Care Act (every now and then the government, at that level, gets something right about our profession).

The educational objective if we follow Dr. Weed is to focus the evidence-supported knowledge base with patient centeredness and wisdom to tell the story of each patient.

In diagnostic imaging, we have a large but still limited number of stories that we call scenarios. We also have an almost unlimited number of patients cared for by a very diverse physician population. These circumstances produce endless subtle variations with regard to our interactions on behalf of patients and their particular story or imaging scenario. We define such a patient story, or scenario as an imaging study, in a particular clinical context, where that diagnostic imaging study should advance and improve the pathway of medical decision-making.

So, to the original question: What three things can better serve those who take on the responsibility of becoming a modern learner of the practice of medicine?

First, we can produce a well-defined, organized, expandable curriculum in diagnostic imaging.

This can be combined with tools that allow for incremental personal exploration of the curriculum and self-evaluation toward a personal determination of competence in a specific component of our specialty.

This self-assessment model must in turn be paired with an independent assessment rubric of attainment of proficiency/competence in those specific tasks. This approach would be wholly aligned with the current movement in Competency Based Medical Education (CBME) (8).

Second, we must adapt our educational processes at the postgraduate level to leverage modern adult learning theory that has evolved over the last 50 to 70 years. (9–12)

These learning theories and techniques support individual styles of knowledge acquisition and critical reasoning and thinking. In doing this, we must place more responsibility on those being educated for establishing their competence than we do on the educators. As we progress, we must abandon the idea that sitting in hour-long lectures or reading books will efficiently accomplish the goal of becoming a capable clinical practitioner.

Third, we must leverage the extraordinary power of Information (Education) Technology in ways that are already practiced in primary, secondary, and graduate education outside of the field of medicine. Primary in this pursuit is the asynchronous delivery of the curriculum and self-discovery assessment tools that monitor progress in acquisition of proficiency. (13)

We must then add access to fundamental technologies that are core to our practice in diagnostic imaging, such as availability of full sets of DICOM images to the trainee. We can use these tools to simulate the most productive educational experience in diagnostic imaging training; the educator and trainee embedded in a clinical problem and consulting with the attending physician (the professionals delivering a diagnosis and treatment plan).

Such an outcome-focussed approach can encourage the beginner to the lifelong student physician in their progress from proficiency/competency to expert in a manner that advances medical decision-making and best serves our patients. (14)


Coming Next: Part 9— Bridging Knowledge, Learning Style and Generational Gaps

I am on a mission to modernize post graduate medical education. With my team at the University of Florida, we have spent the last eight years developing a competency based curriculum and evaluation for radiology, based on modern learning theory. In this essay series, Moving Towards Modern Medical Education and Training, I examine in detail the pathway to modern learning and educational theory, and the outcome of the application of modern learning principles in this sphere of medical education.

Part 1: Medical Education: How Did we Arrive at the Current State

Part 2: “See one do one teach one”

Part 3: Teaching to the Test

Part 4: Competency or Passing the Boards? Every patient wants an expert.

Part 5: Errors and “Experts”

Part 6: Real Experts and Tolerable Error

Part 7: An Invitation to Harm?


References

1- Tennyson, Alfred Lord. Locksley Hall — a poem/dramatic monologue -1842

2- 2- Benedict, Ruth — patterns of Culture, Houghton Mifflin Company, Boston, New York 1934.

3- Weed, L. L. (1964–06–01). “MEDICAL RECORDS, PATIENT CARE, AND MEDICAL EDUCATION”. Irish Journal of Medical Science. 462: 271–282. doi:10.1007/BF02945791. ISSN 1863–4362. PMID 14160426.

4- 2-Weed, L. L. (1968–03–14). “Medical records that guide and teach”. The New England Journal of Medicine. 278 (11): 593–600. doi:10.1056/NEJM196803142781105. ISSN 0028–4793. PMID 5637758.

5- Weed, L. L. (1968–03–21). “Medical records that guide and teach”. The New England Journal of Medicine. 278 (12): 652–657 concl. doi:10.1056/NEJM196803212781204. ISSN 0028–4793. PMID 5637250.

6- Weed LL. Medical records, medical education, and patient care: the Problem-Oriented Medical Record as a basic tool. 1970. Cleveland (OH): Press of Case Western Reserve University.

7- Jacobs L. Interview with Lawrence Weed, MD — the father of the problem-oriented medical record looks ahead [editorial]. Perm J 2009 Summer;13(3):84–9

8- AMA.org- Education-Creating the Modern Medical School.

9- -Knowles, M. (1984). The Adult Learner: A Neglected Species (3rd Ed.). Houston, TX: Gulf Publishing.

10- Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall.

11- Bloom, B., Englehart, M. Furst, E., Hill, W., & Krathwohl, D. (1956). Taxonomy of educational objectives: The classification of educational goals. Handbook I: Cognitive domain. New York, Toronto: Longmans, Green.

12- Krathwohl, D. R. Methods of Educational & Social Science Research: An Integrated Approach. 1st Ed. 1993, 2nd Ed. 1998, New York: Longman, also Long Grove, IL: Waveland Press; 3rd Ed 2009, Waveland Press

13- Understanding by Design® book (Wiggins & McTighe, 1998)

14- Stuart E. Dreyfus The Five-Stage Model of Adult Skill Acquisition
Bulletin of Science Technology & Society 2004 24: 177
The online version of this article can be found at
http://bst.sagepub.com/content/24/3/177

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