The Medical Education in the Digital Era
Raouf Hajji, MD, PhD.
HealthTech Futurist | Professor Assistant of Internal Medicine | Co-Founder & Medical Lead of International Medical Community (IMC)
?The #healthcaresystem is changing dramatically throughout the years. The pace of change in healthcare is accelerating around the world. The concept of #healthcare itself is shifting away from focusing on the #disease towards total health, patient-centered, digital approach to wellbeing with the development of #genomics and #precisionmedicine .
?To be able to provide this system with the appropriate #healthcareprofessionals , #medicaleducation needs to follow the fast pace of the healthcare system and adapt its evolution according to recent technological advances. Doctors and nurses working in healthcare systems around the world are changing the way they learn and work, the way they understand health, and the way they collaborate with patients.
Adopting an up-to-date medical curriculum that can provide us with skilled physicians is crucial for the progression of the #capacities and the #resilience of the #healthcaresystem .
In the 16th Newsletter of @Healthcare Present & Future, we will highlight the visions of many experts of #medicaleducation on the possible pathways that we need to follow to get the best possible #future #physicians :
Medical knowledge is racing away. One of the changes for future Clinicians is that they will need to be comfortable with the notion that they can’t carry all in their heads anymore and they haven’t been able to for decades, admit it. Don’t be afraid to use decision support systems.”
Dr Stan Shepherd, UK, who attended the Clinician of the Future UK roundtable.
Principles of modern medical education:
In the e-book: “Innovative Medical Education in the Digital Era”, the authors had explained that: Innovative medical education curricula may be developed according to the following principles:
? Interactivity. Active learning implies a shift from a teacher-centered class to a student-centered approach that will increase curiosity, boost engagement, and lead to better learning and comprehension. Educational technology should promote interactivity in all teaching settings.
? Bidirectionality. Students should be allowed to apply their knowledge to challenging problems in a setting that promotes collaboration with peers and continuous bidirectional feedback between educators and students and peer to peer.
? Blendedness. New technologies should be integrated with traditional methods. Online lectures, VPs, and online games must integrate traditional lectures, bedside teaching, and group simulations in a comprehensive curriculum.
? Transnationality. Since web-based platforms allow for international cooperation, medical curricula should be transnational and promote contributions from diff erent universities. This would enable homogeneity of training across European countries. It will also improve understanding of cultural diversity.
? Up-to-dateness. The ability to record and broadcast lectures that learners may attend from their own home at their chosen time should not encourage material recycling from year to year. Materials should be accurately checked for up-to-dateness and refreshed continuously.
Innovation in medical education:
It is difficult to define since innovation is not a positive performance in itself. One possible definition is “the application of selected new key practices in education that will lead to an overall improvement.”
For example, in a 2018 survey on innovation in medical education methods, involving students at Concordia University’s Portland College of Education (https://resilienteducator. com/classroom-resources/educational-innovations-roundup/), the following aspects were highlighted:
? Finding any way you can to reach all of your students, by being willing and flexible to adjust what you teach and how you teach;
? Stepping outside of the box, challenging our methods and strategies in order to support the success of all students as well as ourselves.
? Keeping yourself educated about new trends and technology in education and being creative with the resources you are given.
? Allowing imagination to flourish and not be afraid to try new things; sometimes these new things fail but it’s awesome when they are a success; without the right attitude, innovation would just be a word and the art of education would miss out on some great accomplishments.
A wide range of digital technologies is reported in relation to their use for teaching allied health professionals.
The technologies that are most frequently related to practice-based learning are the following:
*??????video-based lectures enabling trainees to harness repetition, self-paced practice, and active learning (Dominguez et al. 2018; Liu et al. 2019);
*??????mobile devices enabling the collection of data related to experience/accommodation of the numerous demands of the highly mobile clinician and trainee;2
*??????audio response systems that off er an innovative approach to teaching and learning, which shows positive acceptance and increased attentiveness (Beaumont et al. 2017; Hussain and Wilby 2019).
These tools stimulate more active learning in the classroom, facilitate student in-classroom participation, encourage group problem-solving, and enhanced engagement and enjoyment of the lecture experience. However, results in terms of long-term knowledge retention and learning outcomes are weak or equivocal (Atlantis and Cheema 2015).
Simulation has recently been incorporated in medical schools, with simulation-based education a rapidly developing discipline that can provide a safe and effective learning environment for students, lead to improvements in understanding of the basic concepts of medical sciences (e.g., pharmacology, physiology), improvement in medical knowledge, familiarity with procedures, improvements in performance and clinical skills during retesting in simulated scenarios (diagnosis, treatment, resuscitation, etc.), and a reduction in medical errors, benefiting patient safety (Khan et al. 2011, McCoy et al. 2017).
Simulation leads to a reduction in teaching time, coupled with an improvement in the speed of knowledge uptake, but is also helpful in cases of depleted resources (e.g., unavailability of animals for experimentation).
Examples of simulation include: SimMan as a tool for training and examination (Swamy et al. 2014; Liu et al. 2019);
Patient safety constitutes a major reason for using medical simulation in order to avoid harm caused by inexperienced trainees and ethical concerns (e.g., circumventing the need for patient consent and confidentiality) (Sorensen et al. 2017). A high-fidelity simulator patient provides a better teaching modality as a blended learning approach for certain tasks, while simulation offers an ideal tool for assessment and evaluation of the clinical skills of students, and the possibility of retraining boosts student confidence.
Among others, these include incomplete mimicking of the human system (which is very complex), defective learning (physical signs are missing, omission of safety procedures, patient consent, etc.), the cost factor (initial purchase and ongoing maintenance costs), time factor, lack of infrastructure, technical difficulties and lack of full-time staff (Qayumi et al. 2014). Although there is no evidence to support the notion that simulation-based learning helps to produce better doctors than traditional teaching methods (Bradley and Bligh 2005), residents trained on simulators were more likely to adhere to the advanced cardiac life support protocol than those who had received standard training for cardiac arrest patients, and residents trained using laparoscopic surgery simulators showed improvement in procedural performance in the operating room (Okuda et al. 2009).
Hence, future studies should help in elucidating the utility and value of simulation in medical education and in assessing the effects of simulation teaching on the patient outcome rather than just assessing short-term goals like the acquisition of knowledge, skills, and student satisfaction (Okuda et al. 2009; Sorensen et al. 2017).
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Virtual reality (VR) is a modern technology that creates a simulation environment. It enhances the user experience by convincing the human brain that it is in a different environment (Riva et al. 2019). VR is useful in, among others, distance learning, special education, training students to perfect their skills in handling patients in different environments, and it has been used by universities as a way of disseminating information about a campus to prospective students before they enroll. Examples include: virtual patients for the online interactive approach to medical education (Cendan and Lok 2012; Baumann-Birkbeck et al. 2017).
A virtual field trip (VFT), used as a stand-alone activity, offers a guided exploration through the World Wide Web that organizes a collection of pre-screened, thematically based web pages into a structured online learning experience. VFTs have been shown to enthuse and excite students, encouraging and supporting the development of a collaborative environment in which both teacher and students take responsibility for the learning that takes place. However, VFTs are less beneficial than real-world experience, and learning opportunities are downgraded if interaction with the real world is limited (Robinson et al. 2009). Moreover, one cannot neglect the fact that VR, in a sense, undermines human interaction, lacks the flexibility offered by live teacher–student collaboration, and calls for high expenditures that only a few can afford, thus exacerbating educational inequalities rather than erasing them.
Augmented reality (AR) is a technology that superimposes a computer-generated image onto a user’s view of the real world, thus providing a composite view. In an era of collaboration and sub-specialization, AR, in the future, may provide a much-needed contribution to educational advancement. AR is used to evaluate dynamic anatomy in real-time through the use of digital ultrasound; it allows visualization of structures and blood flow that can enhance the performance of invasive procedures; it can supplement anatomy education by superimposing radiological (CT or MRI) images onto a body and by creating a direct view of spatial anatomy for the learner; furthermore, with the complementary use of haptic technology, it provides the user with tactile feedback that aids appreciation of the consistency of different tissue components (Kim et al. 2017).
Overall, this represents an exciting area for VR and AR development in anatomical education. The traditional method usually involves the use of an anatomical atlas, time spent in the dissection room, and fixed prosections, while AR and VR deliver a better appreciation of structures in virtual or real space (e.g.,Microsoft Kinect produces an interactive digital mirror that visualizes the structures/musculature, superimposed on the user’s own arm); Dassault Systemes and Anatomage Table are typical examples that allow clinical scientists to immerse themselves in the patient’s anatomy; however anatomic dissection and prosection remain the best and most realistic 3D experiences, while all other systems are complementary methods in the study of anatomy. AR plays an important role in the image-based augmentation of the surgical environment; virtual interactive presence and augmented reality (VIPAR) has developed a support solution that allows remote surgeons to project their hands into the display of another surgeon wearing a headset (Shenai et al. 2011). In fact, according to the Lancet Commission on Global Surgery, 5 billion people do not have access to safe, affordable surgery (Alkire et al. 2015). In addition, live operations using AR have been broadcast to a global community, with feasibility demonstrated for basic procedures both in Paraguay and Brazil (Khor et al. 2016).
Proximie (a collaborative platform) allows surgeons to visualize real-time or recorded operations being performed by experts in other parts of the world (El-Asmar et al. 2021). Although AR and VR appear to be powerful tools, and the literature reveals their versatile emerging applications in medicine, they also give rise to new challenges (Yeung et al. 2021).
Furthermore, the limitations of AR, which include:
Cloud technology is probably the future of technology in education since it hosts apps and services on the internet instead of a user’s computer, enabling information to be stored, shared, and accessed on any device connected to the internet (Mell and Grance 2011). In education, the cloud is used to store and share digital textbooks, lesson plans, videos, and assignments, giving students the opportunity to have easy access with their instructors and other classmates through live chat options; it enables “fl ipped classrooms” (where students can watch a lecture before class and then spend the class time engaged in discussion), group work, and analytical activities (Liu et al. 2015); it reduces the chances of homework getting lost between school and home.
A major limitation to full adoption of the cloud—apart from inadequate access to the internet—is security, however, almost every network in the cloud has a security system in place to protect its information (Liu et al. 2015).
Over the past 20 years, “gamified training platforms” for both pre-clinical and clinical medical education have been developed (Kron et al. 2010, McCoy et al. 2016). The use of gaming in the classroom aims to bring together the fun part of play with the content and concepts that students must learn; gamification increases student engagement, creates enthusiasm for the lesson, provides immediate feedback, and in general students learn better when they are having fun (Hamari et al. 2014). However, not every fun game is effective at teaching a given concept, not every concept is fun, and it takes time and training to learn how to use games effectively for learning (Gentry et al. 2019).
Artificial intelligence (AI) is all about creating machines that can think like humans; it is making its way in to the educational sphere by means of automating grading and feedback, and providing personalized learning opportunities. It can save teachers time by doing the grading and giving feedback on their behalf, and by providing greater insight into a student’s learning patterns. On the other hand, teachers can learn a lot about a student’s learning patterns by doing the grading themselves, while the personal element of care, when a teacher gives personalized feedback (rather than letting a machine generate it), should not be underestimated. Despite the fact that AI algorithms are more cost-efficient than conventional methods, awareness is rising among health experts and managers as to the particular disadvantages of utilizing these technologies; after all, personal involvement and interaction between doctor and patient are of great importance in building trust and successful treatment (Davenport and Kalakota 2019). Although the impressive results of AI cannot be disregarded, apart from increasing concerns about the ethical and medico-legal impact, clinical safety questions must be considered (Challen 2019).
Problem-based learning (PBL) in medical education has been characterized as the most significant educational innovation of the past 35 years (Lim 2012). It is defined as “an instructional (and curricular) learning, student-centered approach that empowers learners to conduct research and students to develop a collaborative spirit.” PBL is a peer tutoring activity and a very effective learning technique by which students undergo brainstorming, and integrate and retain theory and practice in the application of knowledge and skills, to develop a viable solution to a defined problem. It instills many different kinds of skills, such as problem-solving and argumentation rules. A limitation of the method is that student contact hours are four times greater for educators in a PBL curriculum than for educators in a traditional curriculum, thus, the economic viability of problem-based learning is a major concern (Hoidn and Karkkainen 2014). The implementation of evidence-based medicine (EBM), which as a concept developed from PBL, is rightly considered a revolution compared with classical empirical medical practice. Recent technological, scientific, and social developments are likely to transform EBM into precision medicine (Konig et al. 2017). The high-resolution, high-throughput data-generating technologies that continue to emerge facilitate the cost-eff ective generation of huge datasets (Cirilo and Valencia 2019), sophisticated new algorithms and methodologies, and high-capacity computation facilities, giving rise to medicine-based evidence (MBE). MBE is able to build and archive profiles that emerge from all known types of studies and data sources (Knottnerus and Dinant 1997).
what kind of medical education do we seek to deliver?
Appreciating the miracles of technology is one thing; making appropriate use of them is another. A key component of contemporary innovation in medical education is undoubtedly delivered via technology, but the educator still has to play the key role of deciding how to use it appropriately in order to enhance medical students’ critical thinking and problem-solving skills, and not to substitute him/herself as a teacher. In view of this fact, the question is, “What kind of medical education do we seek to deliver?” In essence, this could be rephrased as, “What kind of doctors do we need?”
Technology already plays a huge role in delivering everyday healthcare, but it should be kept in mind that using it effectively should neither undermine the doctor-patient relationship (Chipidza et al. 2015) nor compromise the patient’s right to life-saving and cost-effective care. In this respect, although e-learning offers immense opportunity for high-quality and universally standardized medical training, it will never be able to replace all aspects of real-life, experience-based learning gained with respect to the patient.
The Future Physicians' Responsibilities
Future Physicians skills:
The clinician of the future works in a system that is dependent on digital
technology, and positively transformed as a result. Day to day, most of their
consultations are virtual, and they use interoperable digital health software
to manage patient communication, maintain patient records and help them
make clinical decisions. They have all the data they need at their fingertips,
and technology that uses artificial intelligence to highlight the most relevant
information. Although they need to keep up with fast-changing tech, the clinician
of the future has time for professional development and to build confidence in
new digital approaches, including through developing empathy in a digital setting.