Pedagogical Shifts in Medical Health Education

doi:10.4236/ce.2013.46A004

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Creative Education

2013. Vol.4, No.6A, 20-22

Published Online June 2013 in SciRes (http://www.scirp.org/journal/ce) http://dx.doi.org/10.4236/ce.2013.46A004

Pedagogical Shifts in Medical Health Education

Alberto J . de A rmendi 1, Edmund A. Marek2

1Department of Anesthesiology, Oklahoma University Health Sciences Center, Oklahoma City, USA

2Jeannine Rainbolt College of Education, University of Oklahoma, Norman, USA

Email: alberto-dearme n d i @ouhsc.edu, [email protected]

Received April 24th, 2013; revise d M a y 25th, 2013; accepted June 2nd, 2013

Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any

medium, provided the original wor k is properly cited.

The medical education system has evolved over time and undergone a radical transformation in the past

few decades. With advancements in disease treatments, emergence of new specialties and highly competi-

tive practicing environment, the focus has shifted from gaining knowledge to acquiring degrees. This pa-

per presents 1) where we have been, 2) problems that we have faced, 3) our present status and 4) where

we need to be in the future.

Keywords: Medical Health Education

History

When Abraham Flexner was a research scholar at the Carne-

gie Foundation for the Advancement of Teaching, he described

medical education at the turn of last century as, “students pay-

ing a fee for a diploma for their mediocre medical education”.

The Flexner Report (Flexner, 1910) transformed medical school

education to strictly adhere to protocols of mainstream science

teaching (basic sciences, research, and clinical care) (Cooke et

al., 2006). Since then, multiple reports have criticized the rote

lecture memorization and the regurgitation of scientific knowl-

edge in medical schools. Does passing organic chemistry with

good grades guarantee development of good doctors? Cooke

and others (Cooke et al., 2006) disagree and instead emphasize

the need for focusing on practical and professional skills that

allow for the maturation of reasoning and the development of

professional values and compassion. As Cooke points out, it is

much easier to teach basic sciences than to teach inter-personal

professional teamwork, self-evaluation, and self-improvement.

The single mission of academic medicine is to improve the

health of the population (Ramsey & Miller, 2009). Instead,

healthcare costs have escalated, and waste persists with major

medical errors and patient safety concerns. In 2011, Orszag, as

Director of the USA Congressional Budget Office, reported to

the US Senate Budget Committee that more than $2 trillion is

spent on medical care with $700 billion failing to improve

health care when compared to other countries that spend less.

Medical and health education focuses need to change if we are

going to control the continuous rising cost of health care.

McGlynn and colleagues, researchers at the Rand Corpora-

tion, noted that “In America, there is no guarantee that any

individual will receive high-quality care for any particular

health problem. The healthcare industry is plagued with over-

utilization of services, underutilization of services, and errors in

healthcare practice” (McFlynn et al., 2003). The research also

showed that Americans receive evidence-based healthcare only

50% of the time. Deyo and others (Deyo, 1991) (at the Univer-

sity of Washington showed in their interdisciplinary study,

Back Pain Patient Assessment Team, that what physicians

thought worked well for treating back pain, in reality did not.

Given the status of our healthcare system, what is the present

condition of medical and health education (MHE)? Do MHE

instructors continue to deliver large residential, conference

lectures to health care students in conventional settings? Inno-

vations began in the early 1990s at Harvard University Medical

School. Harvard’s medical education connected the classroom-

learned knowledge to immediate clinical applicability of the

same subject (connecting the basic sciences and the clinical

rotations). A new era had begun. The relationship of classroom

learning and immediate applicability was the buzzword of the

time.

In the early 2000s, problems paying medical schools’ aca-

demic faculty resulted in faculty seeing as many patients in as

short a period of time as possible. This practice was to the det-

riment of the faculty becoming advisors, role models, and

mentors for the new generation of medical students. The loss

included quality teaching. In addition, physicians’ egocentric-

ities did not allow for team building and collaboration with

other health care workers. Intimidation, nested in hidden cur-

riculum, led to abuse and unprofessional behavior toward sub-

ordinates creating an atmosphere of fear and not learning.

Aware of deficiencies in MHE, the Graduate Medical Educa-

tion recognized the importance of self-improvement and system

awareness (ACGME, 2006). In 2006, the Accreditation Council

for Graduate Medical Education set requirements for integrat-

ing six general competencies into the medical school curricula:

1) medical knowledge, 2) patient care, 3) professionalism, 4)

interpersonal and communication skills, 5) system-based prac-

tice, and 6) practice-based learning and improvement. MHE

continues to struggle with how to teach and evaluate these com-

petencies.

Medical and health educators are also compelled to teach

Comparative Effectiveness Research (CER), which offers qual-

ity, safety at lower cost. In other words, what teaching practices

A. J. DE ARMENDI, E. A. MAREK

and learning theories work best at the greatest cost-to-benefit

ratio. The Institute of Medicine (IOM) reported the need to

have a federal CER organizational infrastructure roadmap to set

future CER priorities and to teach CER to every student in

clinical practice. At this time, over 100 priority study topics are

on the website out of over 1250 nominated research proposals

(IOM, 2009). In addition, Crew Resource Management (CRM)

has been shown to reduce medical errors. The future is to teach

interactive dynamics, patient safety, care delivery improve-

ments, communication, and teamwork skills in these settings. In

order for this to occur, we need the convergence of curriculum

reform interests from among all major national stakeholders

(the Association of American Medical Colleges, The Institute

of Healthcare Improvement, the American Medical Student

Association, the Agency for Healthcare Research and Quality

and the Lucian Leape Institute), as well as, the international

academic community.

Present Educational Issues

At present, efforts are underway nationally and internation-

ally at health sciences’ medical centers and at conferences to

incorporate simulation technology to educate our health care

force. Among others, examples include: computer-based virtual

reality simulators, high fidelity and static mannequins, plastic

models, live animals, professional patient-actors, inert animal

products, and human cadavers. Gurusamy et al. (Gurusamy et

al., 2008) evaluated randomized controlled trials and concluded

that virtual reality training can supplement and/or replace con-

ventional laparoscopic training in surgical trainees with limited

or no laparoscopic experience. Ma et al. (Ma et al., 2011) in a

systematic review and meta-analysis of 20 studies on central

venous line catheterization, concluded that simulation-based

education was associated with significant improvement and

benefits in a) learner outcomes (performance on simulators,

knowledge, and confidence) and b) selected patient clinical

outcomes (fewer needle attempts and pneumothorax). Cook et

al. (Cook et al., 2011) in a systematic review and meta-analysis

of almost 11,000 articles prior to 2012, concluded that when

compared to no intervention, technology-enhanced simulation

training of health care professionals was consistent with large

effects for knowledge, skills, and behavior and moderate effects

for patient related outcomes. The authors also question the need

for any further studies showing the benefit of simulation tech-

nology considering that only 4% of the studies failed to show

an association when comparing no intervention to simulation

intervention. They suggest that we focus on clarifying when

and how to apply simulation most effectively and cost-effi-

ciently.

The culture of MHE is gradually changing to a new one of

accountability in quality improvement. In 2001, the IOM pro-

posed six fundamental patient care aims to be learned by health

care students: 1) safety, 2) effectiveness, 3) patient-centered-

ness, 4) timeliness, 5) efficiency, and 6) equitability. A pre-

mium needs to be placed on efficient team-oriented promoters

of quality, safety, patient’s preferences, prevention and well-

ness (IOM, 2001). In 2002, the American Board of Internal

Medicine, the American College of Physicians, the American

Society of Internal Medicine and the European Federation of

Internal Medicine chartered a professionalism creed that states,

“… improvement of quality of care, maintaining clinical com-

petence, reduce medical errors, work with other professionals,

increase patient safety, and optimize outcomes …” (ABIM,

2002). Additionally, in 2004, the IOM reported the need to

teach behavioral and social sciences to equip health care stu-

dents to respond to patients as individuals and not just symp-

toms. The expected outcome was to build better therapeutic

relationships and to be more patient-centered. At the University

of South Florida, a project addressing these issues to surgical

residents exposed to lectures, role model playing, and mentor-

ing reduced medical errors (Brannick et al., 2009). The Univer-

sity of North Carolina uses the Team Strategies and Tools to

Enhance Performance and Patient Safety (TeamSTEPPS) to

prepare medical health care providers. TeamSTEPPS has re-

sulted in physicians reporting 1) prevention in medical errors, 2)

removal of the hierarchical inhibition to speak, 3) time-outs, 4)

sign placement to protect patients, and e) utilization of team

huddles before procedures (AHRQ, 2013). [Other centers are

applying similar educational tools to address all of these areas.]

In the US, we have one of the highest ratios in the world of

physicians/population (25/10,000) trailing Europe and Russia,

30s and lower 40s per 10,000-population, respectively. Other

parts of the world, like most of the sub-Sahara Africa countries,

average about 0.5-1 physicians per 10,000-population (Chart-

Bin, 2013). With such deficiencies in underdeveloped countries,

medical and health educators must resort to preparing the health

care force in th e least expensi ve and most efficient ma nner. For

example, can we teach an adult with an eighth-grade education

to deliver anesthesia in an African country over the internet? Is

that better than having no anesthesiologists, as is the case pres-

ently, in some of those countries? For circumstances like these,

perhaps the future of health care education is global Massive

Open Online Courses (MOOC) or a high-quality online educa-

tional content course available for the international health care

community. These are not online lecture courses, but rather, an

understanding, connecting, and exchanging of ideas through

interaction with others via discussions that form the basis of the

future of education in general (Faust, 2013). Skype is such an

example today. Medical health education continues to advance

through technology by the use of evolving digital computer

innovations, which allow us to share in global knowledge. Both

MOOCs and simulations will lead medical health education in

the years ahead.

The Future

In concluding, health care delivery will change in the future.

Continuously rising costs will be curtailed as the public de-

mands make the profession accountable in quality improvement

and safety. In order to do so, medical school educators need to

change the curricula to emphasize the: 1) integration of patient

care aims to become sensitive patient-centric and customer-

focused rather than provider-centric; 2) introduction of compe-

tencies to self-evaluate, improve and develop lifelong learning

and quality-improvement skills, be system aware, be evidence-

based standardized medical practice, develop interdisciplinary

professional teamwork and evaluate efficiency, quality and

safety; 3) teaching of Comparative Effectiveness Research to

deliver the best effective, efficient, safe benefit-to-cost health

care; 4) decision-making attitudes; 5) formation of data bases to

compare efficacy of disease/treatment results; 6) acknowl-

edgement of accountability; 7) practice of human dynamics,

such as, basic communications and teamwork skills, which

coordinate care efficiently and proactively promoting wellness

A. J. DE ARMENDI, E. A. MAREK

(Kumar, 2011); and 8) incorporation of simulation technology

for quality and collaborative patient-centered care and global

Massive Open Online Courses to facilitate Medical and Health

Education world-wide.

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