There is a growing consensus that traditional approaches to clinical medical education are becoming obsolete.1 Traditional clinical medical education embodied in clerkships, residency rotations, and fellowship experiences is not an effective approach to help medical learners achieve key competencies. The intellectual paradigm, structure, operations, and measured outcomes of contemporary clinical medical education lack rigor and need reform.
Traditional clinical medical education is grounded in 19th-century thinking about the acquisition of clinical competence expressed by Sir William Osler in an address to the New York Academy of Medicine in 1903. The address, titled “The hospital as a college,” was published later in a collection of Osler’s essays titled Aequanimitas.2 The 1903 lecture reflects Osler’s earlier experience with European medical education which he judged superior to the extant American model. Osler states, “The radical reform needed is in the introduction into this country of the system of clinical clerks.…” Osler continues: “In what may be called the natural method of teaching the student begins with the patient, continues with the patient, and ends his studies with the patient [emphasis added]. Teach him how to observe, and the lessons will come out of the facts themselves.”
Osler’s idea about the natural method of teaching was endorsed by his Johns Hopkins surgeon colleague William Halsted,3 who described “the training of the surgeon” in 1904. Osler and Halsted argued that the clinical medical curriculum is embodied in patients—that is, student exposure to patients and experience over time is sufficient to ensure that physicians in training will become competent doctors. This is a passive clinical medical curriculum model based solely on longitudinal patient experience. Osler and Halsted made no place for structured, graded educational requirements; skills practice; objective evaluation with feedback; accountability; and guided reflection for novice physicians to master their craft. The Osler clinical curriculum tradition dominated 20th-century medical education and continues with modest variation into the 21st century.4
The 19th-century model of clinical medical education is expressed almost unchanged in 2015 as undergraduate clinical clerkships, postgraduate residency rotations, fellowship experiences, and continuing professional development that are structured by time (i.e., weeks, months, or credit hours) and location (i.e., clinical site). Although these and other clinical education experiences remain stagnant, they now operate in a complex health care environment where medical education is often subordinate to patient care and financial incentives. Structural and operational expressions of Osler’s natural method of teaching are seen every day at medical schools, residencies, fellowship programs, and continuing education where “time honored” practices (e.g., morning report, professor and grand rounds) are preserved and sustained. These practices have been maintained by accreditation requirements that, until recently, have preserved the status quo and endorsed educational inertia.5
The problem with Osler’s natural method of teaching grounded in longitudinal clinical experience is that it does not work very well, especially compared with contemporary educational technologies. Scores of medical education research studies that span specialties and training levels document skill and knowledge deficits due to ineffective clinical training.1 A recent meta-analytic literature review of mastery learning for health professionals using technology-enhanced simulation identified 82 eligible studies. The goal of this research synthesis was to perform a quantitative summary of comparative mastery learning simulation studies in the health professions. The meta-analytic results show that mastery learning programs are associated with large effects on skills and moderate effects on patient outcomes compared with no intervention. Large benefits for mastery learning were also demonstrated compared with nonmastery instruction but required more time. The authors conclude, “The mastery model may be particularly relevant to competency-based education, given the shared emphasis on defined objectives rather than defined learning time.”6
The message from these and other studies on clinical medical education is clear and consistent. Clinical experience alone is insufficient to guarantee the acquisition and maintenance of clinical competence. Osler’s natural method of teaching based solely on longitudinal clinical experience without curriculum objectives and measurement, performance expectations, learner practice with supervision, rigorous assessment with feedback, high achievement standards, and clear educational milestones is obsolete and simply does not work. A new educational model embodied in mastery learning is needed to ensure that physicians acquire and maintain essential knowledge, skills, and affective and professional outcomes across the educational continuum.
The rest of this Commentary addresses (1) the features and qualities of mastery learning in medical education—including their promise as a new educational paradigm; (2) the order and features of eight more Academic Medicine reports on medical mastery learning that occupy this cluster; and (3) a statement about future education and research directions.
Mastery learning is an educational approach that originates from research and writing beginning with John Carroll7 in 1963 and other early educational scientists including Fred Keller,8 James Block,9,10 and Benjamin Bloom.11 The central tenets of mastery learning are that (1) educational excellence is expected and can be achieved by all learners, and (2) little or no variation in measured outcomes will be seen among learners in a mastery environment.
Mastery learning starts as an educational engineering problem, as articulated by K.A. Ericsson12 in his contribution to this thematic cluster. The key question is, given prospective learners with high educational aptitude and strong achievement motivation (e.g., medical students and residents), how shall we design an educational environment that produces maximum learning outcomes among all trainees? The answer is to create and manage a set of educational conditions—a curriculum and assessment plan—that promotes mastery level achievement among all learners.
Mastery learning is a hybrid approach to competency-based education.13 Mastery learning means that trainees acquire essential knowledge, skills, and affective and professionalism attributes measured rigorously and compared with fixed achievement standards, without limiting the time needed to reach the outcome. Mastery learning results are uniform with little or no variation among learners. By contrast, educational time can vary among learners.
As stated elsewhere,14
mastery learning has [at least] the following seven complementary features:
- Baseline, or diagnostic testing;
- Clear learning objectives, sequenced as units usually in increasing difficulty;
- Engagement in educational activities (e.g., deliberate skills practice, calculations, data interpretation, reading) focused on reaching the objectives;
- A set minimum passing standard (e.g., test score) for each educational unit;
- Formative testing to gauge unit completion at a preset minimum passing standard for mastery;
- Advancement to the next educational unit given measured achievement at or above the mastery standard; and
- Continued practice or study on an educational unit until the mastery standard is reached.
The mastery learning model in medical education conforms with the recent undergraduate priority to ensure medical student readiness for residency education via measured achievement of core entrustable professional activities.15 Measured achievement of graduated educational milestones among postgraduate resident physicians is also well suited to the mastery learning model.16 At a growing number of institutions, medical education at all levels is moving toward competency-based platforms with rigorous measurement of educational outcomes among individuals, teams, and programs. The mastery learning model serves these professional and public interests.
Mastery Learning Cluster
The cluster of articles that address the theme of mastery learning in medical education build a story about this educational technology and how it works. The cluster is organized as four categories of reports that are published in Academic Medicine: Commentaries, Perspectives, Articles, and Literature Reviews.
The story begins with this introductory Commentary followed by a second Commentary by Thomas Inui17 address ing potential challenges within the mastery learning approach.
Matthew Lineberry and colleagues18 then present a Perspectives piece that tackles key measurement and assessment issues in medical mastery learning, especially making valid advancement and summative decisions about medical learners.
K. Anders Ericsson12 amplifies the story with the first of five articles about mastery learning. This is an expression of learning theory and educational best practices about the acquisition and maintenance of medical expertise. This article updates Ericsson’s 2004 Academic Medicine review on these topics19 and presents new scholarly data and insights about the expert performance approach and its contribution to competency-based medical education.
In a second article, McGaghie and colleagues20 cover dissemination of the mastery learning model via implementation science. This involves the difficult transfer of a successful innovation from one educational setting to other locations—barriers, cultural habits, inertia, disincentives—and how such roadblocks can be surpassed.
Setting mastery standards for learner advancement and promotion is a persistent problem that will not go away. Rachel Yudkowsky and her team21 review historical perspectives on standard setting in a third article and argue, from data, in favor of a new approach that emphasizes patient safety and clinical effectiveness.
A fourth article authored by Walter Eppich and colleagues22 addresses feedback to medical learners and its contribution to achievement of mastery learning goals. Effective feedback delivery is informative, is derived from assessments intended for learning, and is a key to medical learner improvement.
Elaine Cohen and others23 present a fifth article on scholarly reporting conventions for medical mastery learning research studies. The reporting conventions are analogous to the CONSORT Statement guidelines for reporting randomized trials. The intent is to ensure uniformity, comprehensiveness, and transparency in medical education research reports that involve mastery learning.
The last scholarly contribution to this mastery learning cluster is a realist synthesis literature review authored by Sharon Griswold-Theodorson and her interdisciplinary team.24 The review documents downstream, translational outcomes from medical mastery learning programs in terms of improved patient care practices and better patient outcomes.
This cluster of articles summarize the current state of affairs about mastery learning in medical education and set the stage for advancements in program development and research.
The current state of affairs is seen in mastery learning curricula now in place in undergraduate medical schools and postgraduate residency programs that set high expectations for learners, provide opportunities of knowledge and skill acquisition via deliberate practice, measure formative achievements and give feedback, coach for learner improvement, and measure outcomes rigorously.1 These curricula are exemplary because they show what can be achieved even in the face of tight budgets, time constraints, patient care pressures, and educational inertia. A growing number of medical education programs now qualify for Berwick’s categories of innovator or early adopter25 as a result of implementing mastery learning curricula.
The technology of mastery learning is now well developed and established in several health professions education settings. Mastery learning program development and research on the horizon will focus on at least two key themes: (1) health care team training, especially teams that are diverse and interdisciplinary with many moving parts; and (2) outcome measurement, especially measures of complex clinical events and conditions (e.g., geriatric type 2 diabetes patient with cardiac and visual complications) that defy assessment using simple checklists or selected response items. Doctors care for complicated patients routinely, and mastery learning curricula must reflect everyday practices. Progress in clinical medical education in general and mastery learning in particular will stem from development of rigorous measures of complex clinical competencies among individuals and teams that are embedded in programs where education and assessment are seamless.26 Advancements will derive from close collaborations involving clinicians and specialists in psychometrics, clinimetrics, and health services research.
Writing in The Structure of Scientific Revolutions, Thomas Kuhn27 defined normal science as
the activity in which most scientists inevitably spend almost all of their time, [which] is predicated on the assumption that the scientific community knows what the world is like. Much of the success of the enterprise derives from the community’s willingness to defend that assumption, if necessary at considerable cost.
Kuhn later argues that a change in fundamental assumptions, a paradigm shift, can spawn a scientific revolution that changes thinking, methodological and measurement practices, even intended outcomes, despite short-run costs. So it is today in medical education science worldwide.
The clinical medical education paradigm has been shifting slowly from a time-based model grounded principally in exposure to patients and much variation in learning outcomes to a competency-based model involving mastery learning where educational outcomes are uniform and learning time varies.13 The time has come for this simple yet revolutionary mastery learning model of medical education to achieve widespread adoption. We must work together as a professional community to reform medical education to advance our commitment to learning outcomes measured rigorously, better patient care practices, and improved public health.
Acknowledgments: Much of the work on the Academic Medicine mastery learning cluster was done while the author was director of the Ralph P. Leischner, Jr. MD Institute for Medical Education at the Loyola University Chicago Stritch School of Medicine. He is indebted to Linda Brubaker, MD, MS, dean of the Loyola University Chicago Stritch School of Medicine, for her endorsement and support of this project.
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. Accessed July 27, 2015
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