Our Near Future: Reflections on Change Agency in Medical Education

Learning Studio (image from UVA School of Medicine website)

I value a recent visit to the University Of Virginia (UVa) School of Medicine. It’s the kind of interaction that gives me hope for the future.  I walked away thinking if a School of Medicine can change 100 years of tradition in one of the most traditional of environments, certainly we should not abandon hope to do the same in our schools. Of course, there are differences, but not as many as we might think. Here’s what I learned:

• Medical students are not always “teacher-pleasing” students. UVa medical faculty made some changes because their own data showed that students were more likely to skip faculty lectures than attend them. It turns out they prefer learning outside of lectures since class content often repeated their text-based content assignments anyway.

• The quality and kinds of assessments used by faculty varied and variables were included in grades that had little or nothing to do with whether the medical students were meeting standards.

• Courses taught by faculty often represented a wide swath of content that had limited relevance to the knowledge needed by skilled physicians. Students spent much of their study time memorizing rote facts they would never use.

• Students were disengaged learners during 8-hour lecture days designated for coursework in the first two years of medical school. They spent a lot of time waiting for the opportunity to apply, analyze, synthesize and evaluate that would occur during “clerkship” rotations in the last two years of medical school. This 2×2 year schedule separated the theory and practice of medicine, creating disconnects.

• Changing the status quo challenges faculty in medical school, too. Abandoning lecture practices that represent how one learned as a student and taught as an educator for years is no easier for a teaching doctor than a high school history teacher.

• Learning new technology skills puts pressure on experienced medical faculty, too. It’s not easy to find that students in class know more about using the technology than the teaching doctor does. Staying ahead of the learning curve is as much of a challenge for medical faculty as it is for a librarian or fifth grade teacher.

• Teaching faculty in medical schools, similarly to many teachers in higher and secondary education also value the dominant teaching wall as an expression of the traditions of teacher “centric” learning. Medical education classrooms typically have been designed and furnished to accommodate frontal teaching.

Here’s how the UVa School of Medicine has changed its medical education program:

Image from UVA School of Medicine website

Staff abandoned a curriculum of content courses taught in isolation. This year, first-year medical student teams learn integrated content deemed relevant to practicing medicine in the context of patient-driven case study. Faculty believe this more natural learning of medical practice increases engagement.

The lecture hall model is no more. These med students mostly engage in class through learning teams. The teaching faculty knows from research that the best patient diagnostic work occurs when doctors are working in teams, not as solo practitioners. They want students to hone skills of teamwork and understand the importance of a professional learning community to sustaining their effectiveness as physicians over their careers. 

Clinical Skills Sim Lab (image from UVA School of Medicine website)

Students no longer work in classrooms. Each learning space in the new School of Medicine has been created to provide a variety of learning opportunities associated with becoming a doctor who serves patients well. The Learning Studio was designed from the MIT TEAL model, Technology Enhancing Active Learning. Students work on cases at round tables, are connected to peers through a network of presentation spaces not a dominant teaching wall, and, well, use technology all the time, really. The auditorium is a working space, not a listening space. Simulations are the name of the learning game to practice real-world medicine. Students may find themselves in high-tech medical simulation spaces, equipped with mannequins or living “standardized patients” with conditions and responses that duplicate the less than healthy you – or me. I also found the student lounge to be a new kind of space for weary learners. Here, students can play computer games, visit, play ping pong, or create music on musical instruments including a grand piano. Faculty believe learning spaces should meet the needs of the “whole” student.

Resources represent state-of-the-art learning technologies. Student work can be projected from a high-tech lectern in the center of the learning studio onto one of several large drop-down screens. Students use multimedia web resources such as 3-D anatomy that’s better than anything except a living patient.

They don’t get assigned print texts- that’s outdated Gutenberg technology. Students use a variety of mobile devices to access digital content created by publishers or their teaching faculty. And those high tech mannequins? They’re so real the students react physically to them as they would in real medical conditions. In fact, the only resource that seems low tech in this environment seems to be the living “standardized patients” who introduce an element of drama into the clinical skills version of a simulation center. The faculty believe that a dynamic, integrated learning context is an improvement over past practice.

Assessment and grading remain a frontier for change inside the School of Medicine. There’s a move towards balanced assessments based on standards, and grading that represents mastery of learning, not variables that have little or no relationship to performance standards. This year, students participate in online formative and summative assessments scheduled on weekends. Multiple measures of performance become the final grade. Most importantly, the goal of the program is success, not failure. In fact, the idea of stratified achievement makes no sense to the leaders of this program. They want all of the students to demonstrate the highest level of achievement possible. To that end, students who don’t master standards the first time, study and retake the assessments.

Faculty committee members monitor the results of these changes on a daily and weekly basis and guide revisions in the process based on the feedback loops they’ve established. They know these changes are costly in terms of financial and time investments. They’ve taken the risk to make these changes quickly because they believe better prepared and engaged medical students will lead to the “end in mind” of well-trained medical practitioners who serve patients well.

The work of UVa’s medical teaching faculty in many ways parallels in-common work of progressive educators in Pk-12 education today.  There’s no doubt that money is an important element in these sweeping changes. However, it’s not the most important element, in my opinion.  The work of staff represents their ownership for the change work and commitment to the students they teach. Despite the basic human drive to sustain the status quo, doctors are professionals who routinely make changes in clinical and pharmaceutical practices as new research indicates those changes are necessary.  This new program is an example of just that.

For more in-depth info, I’ve also posted on the UVA new School of Medicine at http://spacesforlearning.wordpress.com