Back To School: TRAINING DOCTORS
Until recently, medical school curricula had been largely unchanged since Abraham Flexner outlined the Structure/ Process format of medical education in 1910. For most of the past century, students were trained in a binary system: two years of the basic sciences (anatomy and physiology, pathology and bio- chemistry) followed by two years of clinical training. That was fine for a world in which doctors learned, essentially, a trade that was:
- hyper-rational
- focused on sickness and acute care
- targeted at individuals as opposed to communities
- practiced (more or less unchanged) for decades.
But with the explosion of information and technology, the repositioning of the doctor from kingpin to team member, and the recognition that doctors are integral players in an enormously complex system, medical schools are being forced to adapt.
With input from organized medicine (the American Medical Association, the Association of American Medical Colleges, others) curricula have begun to change. Some schools have responded to the call for doctors to be more familiar with the rapidly evolving healthcare environment by adding courses in health systems science, medical economics and quality/safety measures. Competency-based education is gaining momentum. Recognizing that the information learned in medical school becomes rapidly out-of-date, some institutions have incorporated adaptive learning (learning how to learn) into their core training.
EVOLVING MEDICAL EDUCATION
We are in the middle of a paradigm shift in medical education. While there is yet no dominant, overarching philosophy like Flexner’s, competency-based education may well crystallize into its replacement. Medical schools will be labs for experimentation. Gradually, new best practices will emerge. In the meantime, look for the following changes to play out over the next ten years.
COMPETENCY-BASED EDUCATION
-
COMPONENTS
Identifying outcomes
Defining performance levels
Creating a framework for evaluation
Continually assessing programs
-
DOMAINS
Patient care
Knowledge for practice Practice-based learning
Interpersonal/communication skills
Professionalism
Systems-based practice Interprofessional collaboration Personal & professional development
MORE COMPETENCY-BASED CURRICULA, MORE ADAPTIVE LEARNING ELEMENTS
One early example: Stanford and Khan Academy are piloting a program for self-directed medical coursework.
MIXED REALITY
Virtual reality and augmented reality will continue to make inroads into medical education. VR systems allow students to experience surgery more intimately (and at scale) than trying to see over a surgeon’s shoulder, and the addition of haptic feedback to surgical VR training modules will enable students to train in hands-on simulated environments. VR is already being used to enhance empa- thy, for example, by letting students experience life as an 80-year-old man with hearing and vision problems. VR/ AR anatomy will take students inside the body and give them exposure to the dynamics of disease progression, physiological changes and the effects of interventions.
VR currently used in medical education:
- CPR training for medical providers and patients (Next Galaxy and Miami Children’s Health System developing modules to teach CPR)
- Surgery instruction from a rst-person point of view (The Virtual Surgeon by Medical Realities)
- Trauma simulations (Royal College of Surgeons in Ireland)
- Empathy training (Embodied Labs and the University of Illinois, Chicago)
- Anatomy (Unimersiv)
The impact of VR and AR will be felt beyond medical education as they become more integrated into practice. For example, surgeons already use VR to plan and practice surgery before ever cutting the patient.
MD+IT
Technology won’t just change how doctors learn, but what they learn. In addition to EHRs, 70% of physicians used electronic resources during patient consultation hours in 2016, up from 47% in 2014. Medical school curricula and postgraduate training will need to prepare doctors to be more effective using digital tools like messaging, video chat, AR and VR. More students will be offered classes in interpreting AI-generated data and making individual treatment recommendations for specific patients (like a course currently being offered by Harvard-MIT).
MORE THREE-YEAR MEDICAL DEGREES
Currently, there are nine medical schools that offer three-year degrees. More are planned. Though some programs track students into primary care, others offer access to specialty training. First-mover schools will have a competitive advantage for applicants who know the specialty they’ll pursue, want to open time for additional training and/or want to reduce their debt burden.
By compressing core medical curricula (basic science, organ system, core clinical rotations) into 2.5–3 years, medical schools will allow students to gain additional training in nonclinical disciplines—innovation and translational medicine, healthcare policy and organizational science, data science and genomics. For example, Mayo Clinic School of Medicine in Arizona will enroll its first class in 2017, and all students will be awarded a certificate in science of healthcare delivery in addition to their MD. USC offers an accelerated four-year MD-MPH degree.
MORE COMBINED DEGREES, MD + OTHER
MD-MS, MD-MPH and MD-MBA programs will proliferate. There are currently 65 MD-MBA joint-degree programs, more than double the number in 2000. Such ancillary training will also move into post-graduate (residency) training, where elective time may be dedicated to more formal education (graduate degrees, for example).
TEAM PLAYERS, NOT SOLOISTS
Recognizing that medical care delivery is becoming more team-based, schools will shift their focus in the types of applicants they admit. There will be less emphasis on individuality, more on collaborative potential. Tools to evaluate candidates’ soft skills (like the McMaster Multiple Mini Interview) have been adopted by many schools internationally and will gain traction in the United States.
MED SCHOOL 2.0: BALANCED AND FLEXIBLE
Medical school applicants’ attitudes toward the profession will be “push- pull,” both responding to changes in the job market and forcing changes. Expectations of autonomy will adjust downward, both structurally (working as an employee instead of as a practice owner, for example) and in practice (following protocols and AI-generated diagnoses and treatment plans). Conversely, the demand for work-life balance will intensify. More schools will train students for practice in their own systems, e.g., Kaiser’s new school of medicine, opening in 2019.
INTEREST IN PURSUING A MEDICAL DEGREE WILL REMAIN HIGH
Currently, less than 40% of medical school applicants actually gain admission to medical school. Even a significant falloff in applications will still result in most (if not all) medical schools filling their classes.
By 2025, the Association of American Medical Colleges predicts that there will be a shortage of up to 95,900 doctors (35,600 primary care MDs and 60,300 specialists) despite a 25% increase in the number of graduating medical students 2002–2016. The major drivers are an aging population and the Affordable Care Act, which brought millions of new patients into the healthcare system.
However, the rise of nonphysician providers and the influence of technology will be profound, and we predict that the perceived doctor shortage will become a doctor glut for some specialties.