In 1998, I participated in a project with a group of colleagues to consider the future of the specialty of emergency medicine. We had been through 20 years of struggles to describe our specialty to the medical community and the public, develop training programs to prepare residents for practice of the specialty, create assessments of competence, and become recognized as a distinct specialty within the house of medicine. Our motivation for futures planning was to pause for a moment, as if we had just crested a hill during a long run and could now look across the next valley to the higher mountains rising ahead and plan for the coming challenges. We decided to develop scenarios that differed in their perceived likelihood of occurring and their potential consequences, similar to an approach previously used in industry and government and recently summarized by Amer et al.1
I can laugh now at some of the predictions we made,2 such as “Computerization will allow emergency physicians to spend less time record keeping.” Little did we know how time-consuming the electronic medical record would become and how much more documentation would be required for billing requirements. We also anticipated the continued growth of managed care, which was then spreading across the country, and fewer visits to the emergency department, leading to overall declines in reimbursement and the closing of hospitals. We did not anticipate the backlash against managed care and primary care gatekeepers that occurred shortly after our article was published, the explosive growth of our specialty, or the increasing volume of visits to emergency departments, nor did we foresee the scientific advances in treatment of conditions such as myocardial infarction, stroke, and sepsis that require rapid identification and treatment in the emergency department because of the time-sensitive nature of their pathological processes.
While futures planning has inherent uncertainty, the effects on medical education of changes in health care delivery, with new treatments such as those described above, will likely continue to direct many priorities. But sometimes the recognition of new threats to health, such as those from climate change described by Wellbery et al,3 can create a sense of urgency to include new information in the curriculum. At other times, the appearance of new technology, often with associated new procedures, may become the driving force. Ultrasound, which now is used at the bedside to help physicians perform nerve blocks, vascular procedures, and a variety of diagnostic tests, is just such an example. Bahner et al4 have described how ultrasound has gradually been integrated into undergraduate curricula in U.S. medical schools and become a required skill in many residency programs.
To engage our education community in futures planning efforts relevant to medical education, I decided to focus this editorial on themes from published futures planning documents relevant to medical education that were written by expert groups and organizations. Three themes that stood out were (1) information systems and other technology, (2) the increasing costs of health care driving reform of health care delivery, and (3) an evolving global professional identity. While we have published articles on these topics in Academic Medicine in the past, in this editorial I use a futures orientation to consider these topics and their influence on medical education.
Information Systems and Other Technology
New technology will continue to influence all specialties of medicine and medical education, transforming how information about patients and their health conditions is gathered, analyzed, and used for disease management. Imaging modalities will continue to change diagnostic approaches as the ability to peer inside the body will become fast, accessible, and low-risk and will yield rich information. Artificial intelligence modalities will be able to analyze the data from imaging and other sources to create diagnostic probabilities for medical problems and provide guidance for treatment options that may be integrated with telemedicine to provide alternatives to the standard office visit. In this issue of Academic Medicine, Rowe5 describes the potential for machine learning to analyze large datasets and identify patterns that can be helpful in diagnostic decision making. He notes:
Just as clinicians use x-ray and MRI scanners to augment their poor ability to see through objects, so they should use smart algorithms to enhance their intelligence and reduce the impact that cognitive biases exert on their reasoning. . . . The challenge that clinicians are facing is to bring together computers and people in ways that enhance human wellbeing, augment human ability, and expand human capacity.
Many treatments will use robotic technology that may be coordinated with information from imaging. In this issue, Green et al6 describe the challenges of integrating robotic technology into surgical resident education, based on interviews with 24 surgeons. The authors indicate the challenges in skills acquisition by both faculty and residents and stress the need for residents to learn traditional surgical technique in tandem with new robotic skills. The Royal College of Surgery, in its publication The Future of Surgery,7 describes the many ways that technology will alter surgical care and surgical education: “Understanding established and emerging technologies will need to be enshrined throughout education, training, and continued career development.” They add that surgical training is likely to evolve into 3 key components: online training, simulation training, and training in the operating theater on patients.
Starmer et al,8 writing from the perspective of pediatrics, raise concerns about the high cost of technology and its potential to exacerbate current disparities, and ask:
[W]ill the increasing use of technology improve quality measurement and ability to provide demonstrable evidence of a practice’s ability to improve quality in a cost-effective manner? Or, will the high cost of HIT [health information technology] systems widen disparities of quality among practitioners?
They also note that
genomics, molecular biology, nanotechnology, computer simulation, artificial intelligence, and robotics are all emerging as fields that are increasingly present. However, expenses to develop new medical technology are high, which leads to disparity in health outcomes between those who can and cannot afford to pay themselves.
In addition, the availability of personal devices for physicians, students, and patients that can quickly access information will make the mastery of facts less important than the ability to find and use information to answer important questions. While it will still be important for students to have enough familiarity with core bioscientific principles to be able to ask the right questions and make sense of the information they collect, medical education will likely shift into a more conceptual integration of bioscientific principles with the social and environmental factors that influence individual and population health. Frenk et al,9 who are an international group of medical education experts, provide an overview of the future of medical education. They explain that
the next generation of learners needs the capacity to discriminate vast amounts of information and extract and synthesize knowledge that is necessary for clinical and population-based decision making.
Wartman and Combs10 note that
learners also will need to develop a basic understanding of how data are being aggregated, analyzed, and ultimately personalized in health care delivery through artificial intelligence applications. They will need to be able to think broadly about how to manage the variety of applications, whether embodied in decision support software, robots, or more sophisticated social media applications.
In this issue, Wartman,11 in an Invited Commentary, discusses the curricular changes that will be needed to prepare students for the profound technological changes in health care.
The take-home message to me is that medical education will need to help physicians identify, evaluate, select, understand, and manage medical technology and information systems and work with their patients to address health problems. The transmission of basic science content from teacher to student and the testing of memorization of facts will have a diminished educational importance beyond assisting novice students to acquire a vocabulary that will help them understand clinical information.
The Increasing Costs of Health Care Driving Reform of Health Care Delivery
In the preface to the National Academy of Medicine’s publication Vital Directions for Health and Healthcare,12 Dzau et al stated that the fundamental problem of health care for the nation is that health care costs are rising at an unsustainable rate and the U.S. health system has lagged behind international peers in access to care, health equity, and efficiency. They identified 4 priorities: “Pay for value, empower people, activate communities, and connect care.” In spite of a broad recognition of the threats of increasing health care costs in many health care futures scenarios, and a recognition by many expert groups13 of the need to reform medical education to prepare students for needed changes in the delivery system, it is only recently that changes in medical education to address these problems have been actively pursued with organized funding of innovations. Encouraged by grant funding from the American Medical Association (AMA) and legislative changes in funding for health care through the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act, a consortium of medical schools have begun work to integrate health care delivery sciences with basic and clinical sciences.
Skochelak and Stack14 note:
It is time for a new model and approach to medical education in the United States—one that will facilitate the improvements in care delivery and stewardship of resources that our nation requires while more directly meeting the needs of medical students, physicians, health professionals, and patients in the 21st century.
The AMA provided leadership with 11 million dollars over 5 years in competitive grants to medical schools to jump-start the change process and also convened national meetings to discuss progress. As early evidence of this progress, Gonzalo et al15 have described the implementation of a new curriculum with a third pillar of systems science that includes population health, policy, financing, health care delivery, and teamwork to go alongside basic and clinical sciences. In this issue, Gonzalo and Ogrinc16 discuss the resistance to this new curriculum from medical students and suggest steps to overcome such resistance.
The takeaway for me on this topic is that there will be increasing efforts to make health care delivery less costly by addressing the social determinants of health management of patients so that such management can avoid expensive, hospital-based treatments. Our medical education systems will need to prepare our students to participate in and eventually lead the new delivery systems. Since patients will have increasingly central roles in their care, a curriculum that interweaves patients’ stories, experiences, and needs with the critical bioscientific and social sciences contributions to health could help guide students and residents toward more effective stewardship of health care costs while fostering high-quality care.
An Evolving Global Professional Identity
Irby et al17 defined professional identify formation in students and residents as “the development of their professional values, actions, and aspirations.” Professional identity formation involves the transformation of a student whose focus upon entering medical school has typically been on individual learning about the bioscientific principles of disease into a physician whose focus is on the meaning and effects of a disease or injury on a patient and that patient’s community. Frenk et al9 have globally applied the vision of Irby et al, noting that
all health professionals in all countries are educated to mobilize knowledge and to engage in critical reasoning and ethical conduct, so they are competent to participate in patient-centered and population-centered health systems as members of locally responsive and globally connected teams. The ultimate purpose is to assure universal coverage of high-quality comprehensive services that are essential to advancing opportunities for health equity within and between countries.
They go on to describe 3 levels of learning:
- informative, which is about acquiring knowledge and skills;
- formative, which is about socializing students around values; and
- transformative, which is about developing leadership to produce change agents.
In this issue, Adema et al18 describe the development of professional identity during clerkships. One of the students whom the authors observed expressed what I believe is the ideal of a global identity that medical education can inspire:
We talked a lot about the world, what is good and what is bad . . . and I am frustrated about this . . . and I think, “I want to contribute, I want to help,” but this is not possible right now. And for me, this is a confirmation [of] why I study medicine, namely, to help people and to be able to board a plane to offer my help somewhere.
I believe that the development of a global professional identity in our students will help us guide the use of technology, information systems, and changes in our delivery systems that will improve quality and reduce costs, ultimately taking us in the direction of improved health equity. The important message for me about this theme is that it recognizes the importance of engaging the minds and souls of our students and practicing physicians through our educational programs so that they see themselves as global citizens, serving the needs of all people and the planet on which they live. The way they use the knowledge and skills they acquire should reflect these ideals.
My final comment occurred to me when I was reviewing futures planning documents. In those documents, a variety of scenarios are proposed to stimulate creative thinking about what actions organizations or groups should take to prepare for each scenario or some combination of them. There is an assumption that the goal is to manage the future, whatever it might be. My concern upon reading the scenarios was that some of them presented significant crises in the future—wars, serious effects of climate change, and emerging disasters from infectious diseases. While planning for such catastrophes is important, I worried that in our efforts to prepare for such disasters and survive them, we may become distracted from what I believe should be our primary responsibility: to prevent these disasters from occurring.
In that regard, I recently attended a lecture that contained information about the scenarios that the Accreditation Council for Graduate Medical Education has been using for its current futures planning. Nasca and Thomas19 described some insights from this process but did not mention the dire scenarios I had heard in the lecture. While I do not want to be an alarmist, if expert futurists believe there is even a 10% chance that our coastal cities will be inundated because of rising sea levels or that places like Phoenix where I live will experience temperatures above 125 degrees Fahrenheit by 2035, we in academic medicine ought to be discussing which actions we need to take now to prevent these things from happening. If we wish to inspire our students to assume a global professional identity, we need to think and act globally to prevent catastrophe rather than just figure out how we will survive and thrive in a world in crisis. This is our challenge and our responsibility—to do what is needed to avoid the dire scenarios and to train students who will help realize the optimistic scenarios for the world’s future.
David P. Sklar, MD
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