On October 4 – 5, 2013, the American Medical Association hosted the “Accelerating Change in Medical Education Conference” in Chicago, IL., bringing together leaders in the realm of medical education for discussions aimed at “closing the gap between current physician training and the needs of our evolving health care system.”
For those of us who grew up in this century, the adage that technology is changing the world and that the speed of this change is accelerating has passed into cliché. Yet, at the conference, where leaders of medical education convened to discuss the future, I came to realize that my view was too narrow to realize how broadly these changes are affecting and will continue to affect medical education.
As Dr. Rich DeMillo, Director of the Center for 21st Century Universities at Georgia Tech and the closing plenary speaker described, the effect of technology on education is like an accelerating train. “Sometimes,” he said, “I feel like I’m strapped to the front, and I don’t know whether we are going to hit a barrier or just go right through.” As AMA President Dr. James Madara noted, “In the past century since Flexner wrote his famous report condemning the quality of medical education, the United States has advanced from a backwater of unstandardized schools to one of the most highly regarded higher education systems in the world.”
However, as Madara stated in his plenary session, five-year plans are not enough to envision the future of medical education. “If your vision drops off after five years,” he said, “your aspirations are just not great enough.” In the short run, he pointed out, we may underestimate the possibilities for innovation, but in the long run, we are bound to underestimate what will be seen as the innovations of the future.
Despite somewhat different backgrounds, both speakers held remarkably similar views on medical education. They saw the current system as unsustainably high in capital investment. Madara, formerly the CEO of the University of Chicago Hospitals, revealed that only after he was outside of the academic medical center system did he realize how trapped he was within the structure of the institution. Whether by building a new hospital or by making a course within a biochemistry department, academic medical centers have so many resources tied up in the preexisting systems that even incremental change requires an extraordinary amount of work, and revolutionary change appears impossible.
DeMillo also argued that we have known since Flexner’s time that lecture-based learning was ineffective. However, most schools remain constrained by the lecture-based structure with the substantial associated investment in a large teaching faculty because individualized learning seemed “too expensive … until now.” Now, with modern technologies of open online coursework, including massive open online courses like Coursera and EdX, DeMillo noted numerous examples throughout the country where online learning was proving to be cheaper, reaching more people, and enabling more individualized education than any analog classroom.
Both speakers described a future where medical education would be decentralized and “in the cloud.” Students could learn from professors across the country—or across the world—and there would be no need for physical classrooms. In Madara’s view, the clinical years would move from being based at academic medical centers to being based where clinical practice will actually be: at patient-centered medical homes or even within patients’ homes. He envisioned future academic medical centers would become streamlined “solution shops,” which would bring specialists together to handle transplants, critical care and other complex cases. Under this decentralized paradigm, training sites would be known not for their teaching faculty or their curriculum, as the best of these would be available to any medical student nationally, but the quality of their clinical training and the unique health systems or community-related assets available at a particular training site.
Madara and DeMillo’s vision is attractive in many ways. It addresses many of the problems in medical education today, ranging from high capital costs to siloed, lecture-based teaching. It enables 30,000 different medical education curricula for the 30,000 new medical students. It pushes for medical education to exist outside the physical space of an institution and provide care for patients where they are. It capitalizes on technology’s potential to allow training programs to prepare its students for a medical system that does not yet exist.
However, even on theoretical grounds, it raises many concerning questions for the future. Do we want the medical students of the future to choose which of the many tracks they want to “specialize” into from the beginning of medical school? Will online coursework cause medical schools to lose out on the existing professional camaraderie and perhaps more critically, the group discussion and reflection? Only time will tell.