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The Empirical Challenge of 21st-Century Medical Education

Wartman, Steven A. MD, PhD

doi: 10.1097/ACM.0000000000002866
Invited Commentaries
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Medical education is at a crossroads. Facing challenges wrought by science and technology as well as societal change, the curriculum is increasingly out of synch with new needs in teaching content and medical practice. The path to significant curricular reform is difficult because of a variety of factors, including deeply entrenched values, the natural resistance to change, and the accreditation process. Indeed, even the very definition of what it means to be a professional is changing with profound implications for the future role of the physician and the sacrosanct doctor–patient relationship.

In this Invited Commentary, the author enumerates challenges facing medical education in the current era. To address these challenges, the author recommends specific curricular emphases for 21st-century medical education: knowledge capture and curation, collaboration with and management of artificial intelligence applications, a deep understanding of probabilistic reasoning, and the cultivation of empathy and compassion in accordance with ethical standards. Given these needs, it is imperative that schools act today to undertake significant curricular reform and, in so doing, strive to make the hard changes necessary to produce optimal practitioners in a rapidly transforming 21st century. The author provides first steps an institution can take to begin to address these challenges.

S.A. Wartman is president emeritus, Association of Academic Health Centers, Washington, DC.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Disclaimer: This Invited Commentary represents solely the views of the author.

Previous presentations: This Invited Commentary is based on the 2019 Brodie Medical Education Award Lecture given by S.A. Wartman at the University of Virginia Medical School, Charlottesville, Virginia, February 27, 2019.

Correspondence should be addressed to Steven A. Wartman; email: swartman@aahcdc.org.

Medical education has always been challenged to keep pace with advances in science and technology, and this is certainly true for the current era, when these advances are arguably more rapid than ever before. But there is a deeper aspect to the current challenge in medical education, namely, the profound cultural shift taking place as our civilization transitions from a print-based industrial society to a technology-based Internet society.1 The hallmark of this shift has been described as the “technological convergence,” where a large and ever-growing range of digital technologies—such as robotics, big data, artificial intelligence (AI), and social networking—are increasingly working together to create powerful new applications.2 A technology-based Internet society presents at least 4 existential challenges to medical education.

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Challenges to Medical Education in the Current Era

The meaning of being part of a profession

Traditionally, a “professional” has been defined as the exclusive bearer of a body of knowledge. But today the rapid dissemination of medical information outside of the profession is diminishing its exclusivity. This is true not only for information but also for skills that are increasingly being performed by machines. As a result, the profession of medicine is facing a loss of control in both information management and its unique expertise in many areas. Consequently, the roles of physicians and other health professionals are changing, often without the direct input and leadership of the profession itself. Reflecting on the status of a different profession—journalism—a former editor commented, “Our generation had been handed the challenge of rethinking almost everything societies had, for centuries, taken for granted about journalism.”3 One can easily substitute “medicine” for “journalism” to appreciate the vastness of the challenge facing medical professionals today.

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The importance of distinguishing information from knowledge

The freedom to find and choose information today is virtually unlimited. A casual online search for any medical condition, regardless of how common or obscure, reveals many dubious or untrue “facts” and recommendations amidst an overwhelming plethora of algorithm-based “hits.” Decision making in medicine is increasingly being shared with those outside the profession, but it is important to note that what is generally shared is information, not knowledge. Information is the presentation of “facts,” while knowledge is based on understanding what is being presented. To achieve understanding, “facts” need to be curated, that is, they need to be selected and organized to present professional and/or expert knowledge. Medical students are expected to master large amounts of information—but, in so doing, are they obtaining sufficient knowledge? Information curation in medicine has traditionally relied on journals, textbooks, professors, and “leading experts.” But there is currently no defined methodology to ensure that medical students have mastered the ability to curate information, an increasingly urgent challenge in an era of virtually unlimited medical information.

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The management of AI applications

Machines can already outperform humans in many tasks (e.g., pattern recognition, some surgeries, data storage and recall). They have many advantages over humans: They do not get sick or tired, their abilities do not decline with age, they can easily be updated to reflect the latest advancements, and they do not require bureaucracies to manage their affairs. In a well-received book on the future of the professions, Susskind and Susskind1 predicted that

machines and systems will work alongside tomorrow’s professionals as partners. The challenge here is to allocate tasks, as between human beings and machines, according to their relative strengths. . . . Human professionals will have to come to terms with the need to defer to the superior capabilities of machines.

A good example of the professional challenge in this area is the ability of the human clinician to fully understand the probabilities generated for diagnostic and therapeutic options derived from AI (e.g., Watson). As the collection of huge patient metadata sets becomes standard (eventually leading to continuous monitoring), a new interpretive and functional infrastructure is required for clinicians to manage and apply this information to clinical decisions. As noted by Hunter,4

The new tools for tailoring treatment will demand a greater tolerance of uncertainty and greater facility for calculating and interpreting probabilities. . . . Assessing and acting on these probabilities will require approaches to data presentation, risk quantification, and communication of uncertainty for which we are largely ill equipped and that we already struggle with.

It is essential that medical students develop the skills to understand—in depth—the probabilistic implications of such data.

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The future of the sacrosanct doctor–patient relationship

The relief of suffering, consisting of physical pain and all forms of mental distress, is the ultimate goal of patient care. The profession’s response to suffering rightly begins with compassion, characterized as “suffering with the patient.”5 Practicing with compassion is a significant challenge in medical education for many reasons beyond the formal curriculum. Barriers include the selection criteria used for medical school applicants, the traditional view that clinicians need to maintain a certain distance from patients to remain objective, and the notion held by some that compassion is not a skill that can be taught effectively. As the roles of technology and AI applications grow in medical practice, the profession risks losing the sacrosanct nature of the doctor–patient relationship. If “[t]here are some things people come to know only as a consequence of having been treated as human beings by other human beings,”6 then a serious and concerted effort must be made to ensure that compassionate care remains a critical component of medical practice in the age of artificial intelligence.

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Curricular Reform to Date

The past decade has seen a flurry of curricular reform that has improved the content and relevance of medical education. Among the many examples are the use of simulation and standardized patient technologies; small-group learning and flipped classrooms; earlier clinical and community-based experiences; time-flexible competency-based learning; and increasing input from the social sciences, engineering, ethics, arts, and humanities. The newer medical schools in many cases are able to take the lead in these efforts as they are not as burdened as older institutions with the challenges of tradition and cultural change. Nevertheless, it is an open question as to whether these changes are incremental in nature or whether they are effectively and substantively changing the medical education paradigm in a timely enough manner. In my view, the process of curricular change to date, while evident at many levels, is falling behind the pace necessary to meet the challenges discussed above.

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Curricular Emphases for 21st-Century Medical Education

As the practice of medicine advances in today’s highly dynamic and changing environment, the medical education curriculum struggles to keep pace. Four areas in particular should be emphasized in the current era of medical education and beyond.

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Knowledge capture and curation, not information retention

The amount of potentially relevant medical information far exceeds the capacity of the human mind. Yet the typical medical school curriculum focuses on information retention more than knowledge capture and curation. An essential skill for the 21st-century physician is learning how to find and understand information that is trusted and accurate. This effort should permeate all aspects of the medical school curriculum.

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Collaboration with and management of AI applications

As AI applications take on larger and increasingly significant roles in medical practice, students must understand in depth the strengths and weaknesses of these machines and, importantly, how best to manage and collaborate with them. The human–machine interface should occupy significant curricular attention.

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Understanding probabilities and communicating and applying them meaningfully

AI diagnostic and therapeutic algorithms present conclusions largely in the form of probabilities. Clinicians must have a deep understanding of statistical processes as they work with big data and predictive analytics. Further, being able to communicate these probabilistic statements to patients in a personalized and meaningful way requires both training and expertise, including an understanding of the psychology of choice and the heuristics of decision making.7

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Cultivation of empathy and compassion in accordance with ethical standards

The cultivation and mastery of empathy and compassion, especially in the age of information overload and technologic convergence, must be the foundation of the profession. These skills should be modeled and taught and should be emphasized throughout the curriculum. This is a substantial challenge for medical educators, involving every aspect of student engagement. Obviously, this cannot be reduced to a single course or a couple of lectures; rather, it must be viewed as an integrated component of the entire curriculum. Students must become competent in respecting the rights of patients to make choices according to the patients’ own values, including understanding how these values impact care decisions. Ultimately, the curriculum should provide students with real and tested abilities to offer the human services that patients need—to go beyond probabilities to address uniquely human complexities—all while adhering to the highest ethical standards. Learning to cultivate empathy and compassion for the suffering of patients must be a consistent theme throughout medical school.

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The Challenge of Substantive Curricular Reform

Medical education curricular reform has been a gradual process despite many compelling calls for substantive change. As Skochelak points out, “Every decade brings calls for improvement in medical education.”8 The challenge of reform is, of course, not limited to medicine but is endemic amongst professions in general: “[A]ll professions seem to share the bias of finding difficulty in imagining any thoroughgoing reengineering of their own discipline.”1 Most medical schools are managed conservatively, are risk-adverse, and are staffed by highly accomplished individuals who tend not to view themselves as beholden to administrators. A granular perspective on medical education reveals many untested assumptions and a curriculum full of requirements in response to regulations, trends, and topics du jour. Curriculum committees, as they contemplate change, often reflect the “mini-me” syndrome, in which participants strongly advocate for content that mimics their professional leanings. Entrenched faculty worry about loss of curricular time and growing irrelevancy. In some cases, the teaching skills of faculty are outdated compared with the learning styles of their students. And accreditors, in their efforts to maintain control, contribute to making significant changes difficult. The result is that medical education reform is caught up in a nexus of contrary forces. However, the price of the status quo is that medical education becomes increasingly disconnected from contemporary practice while continuing to take an enormous psychological toll on students, residents, and teaching faculty.9 The current focus on enhancing the resilience of students and residents, while noteworthy, should not serve as a substitute for substantive and systemic curricular reform.

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What One Institution Can Do: First Steps

Given the compelling need for change in the face of numerous entrenched constraints, a medical school might be discouraged from pursuing meaningful and far-reaching curricular reform. There are, however, some initial steps that institutions can take to get the process of education reform moving forward.

Importantly, these first steps are mainly inward-looking and necessary to gain an in-depth understanding of what the school wishes—and is able—to achieve. Because each school has its own inherent values, goals, strengths, and weaknesses, the process of curriculum reform should not be sidetracked in its early stages by a time-consuming review of what other institutions are doing. Rather, the aim of these initial steps is to set the table for an honest and introspective discussion with the goal of developing a deep understanding of the kind of education reform that is both desired and appropriate for the institution. A thoughtful elaboration of the issues outlined below should involve a facilitated discussion and last at least 1 full day or more.

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Determine if our institution is currently educating students to be maximally effective 21st-century practitioners

The discussion around this question should focus on current and perceived trends in health care delivery and education technology. It should consider many of the issues raised above.

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Explore why/how our curriculum should be different from any other school’s

This is a deceptively difficult question. It broadens the discussion to consider the unique attributes of an institution, including its intellectual, social, and political environments, as well as broader institutional goals and priorities.

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Commit to reimagining every aspect of education and training

Essential to this exercise is the need to put every curricular component on the table for critical consideration with the caveat that all ideas should be guided by how students can best learn what ultimately benefits patients most. Topics beyond the various curricular components should be included as well, such as how applicants are selected, how students are evaluated and supported, and how faculty teaching skills can be tailored to curricular and student needs.

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Identify some strategies to overcome institutional inertia

Change is always difficult because of natural human resistance. Faculty and administrators are generally comfortable in their current roles and feel validated by them. Yet, “Institutions will try to preserve the problem to which they are the solution.”10 This issue should be discussed openly, and strategies to overcome institutional inertia should be developed.

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Ensure that the cultivation of compassion permeates all aspects of the curriculum

The importance of the cultivation of compassion in students is not to be underestimated, especially in the era of smart machines and unlimited amounts of medical information available to the public. Compassionate care is the cornerstone of the doctor–patient relationship and should be viewed as a unifying curricular theme.

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Enable education, research, and patient care to work together to create a learning health care system

An institution should make every effort to take advantage of the strategic synergies that can arise by creating a virtuous cycle connecting education with research and patient care in a continuous feedback loop. Unfortunately, in many institutions, these connections are not sufficiently prioritized with the result that medical schools fail to take advantage of a powerful dynamic whereupon each component regularly improves the performance of the others. The ultimate goal is the creation of a real-time learning health system, in which the practice and teaching environments learn from each other and are informed by research.

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Concluding Comment

Ideas for medical education reform present mainly an empirical challenge, that is, they are based largely on observation and experience rather than strictly on theory or logic. Thus, the implementation of curricular change requires an open mind, a willingness to take risks, and transformational leadership. As indicated by the “first steps” recommended above, institutions must initially commit to an honest and in-depth scrutiny of their current program and then develop strategies tailored to begin a successful process to achieve the changes desired. One roadblock to significant education reform involves the accreditation process. It is enlightening to review the history of accreditation to observe how, over time, schools are increasingly subjected to an open-ended constellation of requirements. This is not to impugn the intent of the process but, rather, to note that this evolution is typical for business entities (for-profit or nonprofit) to retain their hegemony in a growing and changing field. Further, faculty who serve on accreditation bodies have invested part of their professional careers and reputations in this kind of work, presenting schools with an ingrown source of resistance to change. Nevertheless, given the urgent need for substantive curricular reform, one of the following potential regulatory outcomes seems likely: the development of a true national curriculum for medical schools with minimal room for deviation, a greatly scaled-down list of basic requirements that permit schools to have far more flexibility, or the creation of new competitive accreditation organizations that offer schools a fresh approach. Regardless, it has never been more important for the content and substance of medical education to respond to the profound societal changes taking place. It is imperative that faculty and leadership become deeply involved in the process of education reform by striving to make the hard changes necessary to produce optimal practitioners in a rapidly transforming 21st century.

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References

1. Susskind R, Susskind D. The Future of the Professions. 2015.Oxford, UK: Oxford University Press.
2. Olawuyi JO, Mgbole F. Technological convergence. Sci J Phys. 2012;Article ID sjp-221. doi:10.7237/sjp/221.
3. Lepore J. Does journalism have a future? New Yorker. January 21, 2019. https://www.newyorker.com/magazine/2019/01/28/does-journalism-have-a-future. Accessed June 27, 2019.
4. Hunter DJ. Uncertainty in the era of precision medicine. N Engl J Med. 2016;375:711–713.
5. Campbell J, Moyers B. The Power of Myth. 1991.New York, NY: Anchor Books.
6. Weizenbaum J. Computer Power and Human Reason. 1976.New York, NY: W.H. Freeman and Company.
7. Tversky A, Kahneman D. The framing of decisions and the psychology of choice. Science. 1981;211:453–458.
8. Skochelak SE. A decade of reports calling for change in medical education: What do they say? Acad Med. 2010;85(9 suppl):S26–S33.
9. Slavin SJ. Medical student mental health: Culture, environment, and the need for change. JAMA. 2016;316:2195–2196.
10. Kelly K. The Shirky principle. The Technium. https://kk.org/thetechnium/the-shirky-prin. Accessed July 1, 2019.
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