The Marvelous Medical Education Machine or How Medical Education Can Be Unstuck in Time

The jumping-off point for this paper is actually the second part of its compound title. The concept of becoming “unstuck” in time stems from the initial line of Kurt Vonnegut's popular novel Slaughterhouse Five Vonnegut 1969: Listen: Billy Pilgrim has come unstuck in time. In this paper I will actually argue that medical education has become “stuck,” not only in time but also in space and content. It has become stuck in time because events considered to be educational largely occur through interactions that require the learners and the faculty to be simultaneously participating in these interactions. It has become stuck in space because its mechanisms of delivery are largely bound to a specific physical location, the academic medical center with its classrooms and associated health care delivery venues. It has become stuck in content because the topics that are the focus of educational interactions are insufficiently under the control of the students, and the teachers. Increasingly, there is no reason for any of these requirements to be imposed on the educational process. Moreover, medical education remains stuck in an era when much of the rest of human enterprise is becoming unstuck, the result of a sweeping set of cultural changes made possible by information technology and primarily by the phenomenal proliferation of the global Internet Drucker 1999. I will further argue in this paper that medical education can gradually be “unstuck” in space, time, and content through appropriate use of emerging technology, with emphasis on simulation methods that have become widespread in the use of training pilots and professionals in other disciplines. Modern flight simulators have become so sophisticated that experienced pilots being certified to fly a new aircraft might have a load of passengers in the back the first time they actually fly the plane Dawson and Kaufman 1998. While there will always be a pilot experienced flying this aircraft alongside the neophyte in the cockpit, this practice clearly testifies to the educational power of simulations. Recently, the U.S. Navy adopted the inexpensive Microsoft “Flight Simulator”™ program as standard training for its new pilots, after a trainee who practiced extensively on this program recorded the best performance ever on an initial training flight Brewin 2000. The “marvelous medical education machine,” as the concept will be developed in this paper, is the complete simulator for medical education, analogous to the best of contemporary flight simulators. But like Vonnegut's novel, the marvelous machine is currently a work of fiction. It does not exist, although bits and pieces of it do exist, and these suggest what might be possible in the not-too-distant future. In the sections that follow, I will describe the need for the marvelous machine in greater detail, discuss what it can potentially do when built, expose the internal anatomy of the complete machine, review some of the pieces that exist now and how we might build it from here, and finally discuss some of the key educational research questions that will have to be illuminated along the way. This paper, in its entirety, will argue that building the marvelous machine should be a top priority for medical education nationally and internationally. Stuck in Space, Time, and Content To clarify what it means for medical education to be “stuck,” it may be useful to consider education as a process with events that exist in three dimensions (Figure 1). The first dimension can be thought of as physical space, the second time, and the third the biomedical topic that is under consideration. Medical education is stuck in all three dimensions, because teachers and learners have little control over these dimensions: where and when the events occur and what topics are addressed. In the basic sciences, for example, lectures and labs occur in a fixed place and at a scheduled time and on a topic that faculty believes the students need to know about—and then they are over. In the clinical sciences, patients (who remain the primary “teaching material” even though this term is seldom used anymore) appear at a fixed location and at a particular time with the problem they happen to have—and then they leave.Figure 1: Traditional medical education is “stuck” in the dimensions of space, time, and content.This way of doing educational business is so much a part of daily life in an academic medical center that most of us take it for granted; and since our students learn and graduate and become certified as practitioners, it is easy to conclude that there is nothing wrong with being “stuck.” But there are profound reasons for concern. First and foremost, education that is stuck routinely ignores much of what is known about teaching and learning in medicine. Studies of clinical reasoning accumulated over more than 20 years point to the “case specificity” of medical expertise, meaning that proficiency generalizes very weakly from disease to disease and, more generally, from one aspect of medicine to another Elstein et al. 1978; Schmidt et al. 1990. As such, the most effective way, and perhaps the only way, of developing proficiency over time is active practice with a wide range of cases and with as many repetitions for each subject/disease area as possible Issenberg et al. 1999. In educational environments that are stuck, live patients are the primary source of such practice; yet faculty and students have no control over the patients who walk into the clinic or are admitted to the hospital. Active, appropriate practice under these circumstances can be very difficult to engineer, much less guarantee. Another problem is the expectations of a coming generation of learners that has increasingly “grown up digital” Tapscott 1998. Our students who have experienced increasingly sophisticated video games, and who have spent hours with such excellent simulations as Sim City™ and Flight Simulator™, will recognize immediately the potential for similar experiences to enhance their training in medical domains. These learners will intuitively understand that medical education is stuck in space, time, and content. Although they may not use these exact words, they will find being stuck unacceptable. They may articulate this recognition by comparing their medical education experience with their undergraduate experience, wondering why, as the sophistication level of what they are studying is increasing, the sophistication of the technology used to support these studies is decreasing. In the short term, they may accept what they see as antediluvian educational practices, simply because these represent the only pathway to a desired profession, but over time they will demand a different kind of service, the need for which and the practicality of which they see as self-evident. If they cannot get this service from traditional educational institutions, their instincts honed by the Internet culture will lead them to seek it from other sources. Economic pressures on academic medical centers may drive change as well. The problem of providing appropriate practice for trainees exacerbates as health care economics shortens hospital stays and clinic visits, and trainees necessarily have more limited access to patients. Clinical faculty members at academic medical centers and in community settings may perceive that their productivity is judged much more by patient throughput than student learning. An educational system already limited in its ability to provide an appropriate range of “teaching material” may find itself unable to provide appropriately motivated teachers as well. If academic medical centers do not systematically recognize the opportunity afforded by information technology to “unstick” the system, others will. Hafferty has warned that, for a variety of reasons, medical education based in academic centers could lose its social mandate by not addressing in the curriculum a widely-recognized set of social needs, and thus become irrelevant to the needs of the modern world Hafferty 1999. Similarly, by remaining obstinately stuck in space, time, and content, academic medical centers could lose what may be called their “technical mandate” to educate because the methods being used no longer make sense to trainees and to society as a whole. Simultaneous loss of social and technical mandates will generate alternative approaches to education that could, over time, become the norm. Such alternatives are already becoming evident, for example, in the Open University's plan to offer a curriculum equivalent to the first two years of the medical curriculum in the United Kingdom Daniel 1999, and possibly through Internet ventures such as “medschool.com”™ Medschool.com 2000. Established academic medical centers can choose to be leaders and active partners in these developments, or not. Some may ask to what extent the technique of standardized or simulated live patients Ainsworth et al. 1991, which has occupied much of the attention of the medical education research community over the past two decades, offers the capabilities of the marvelous machine. It does, but as a practical matter only to a very limited extent. Standardized patients are expensive and do not offer the economies of scale that, as will be discussed, the marvelous machine so profoundly offers. The largest expense associated with use of standardized patients is the wages they must be paid, and the 20th standardized patient encountered by a student costs almost as much as the first. Standardized patients must be painstakingly trained, and there are significant costs associated with this training that are completely lost once the patient retires from active educational service. And a standardized patient can offer only limited variations on the case he/she was trained to represent. As a trainer for procedures, standardized patients must endure the mistakes of the non-expert. Invasive or risky procedures cannot ethically be performed on them at all. Although they can explain how they feel, standardized patients have no access to what is actually happening inside their bodies, and cannot explain to trainees the consequences of their actions at the organic or cellular levels. Finally, standardized patients cannot easily record what is being done to them by the trainee, so feedback to trainees cannot be related with high precision directly to their actual actions and decisions. So while standardized patients can be enormously valuable sources of practice and tools for assessment, they take medical education only part of the way to where it can and needs to go. They are, for the most part, stuck in space, time, and content. Potential of the Marvelous Machine Remember above all that the marvelous machine does not currently exist. As we consider what the future might hold if medical education begins a steady progression toward the development of the marvelous machine, it is useful to visualize an end-point of this progression. I do not envision, ever, the complete elimination of teaching around live patients in the same sense, although some might disagree, that no novice pilot is likely to receive a license without flying a real plane. Nor does this work envision that will their first after years of practice only on a I envision a future where medical and for their education, increasingly of their time on simulators. 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