Medical education without medical educators.

Editor – The onslaught of computer-aided instruction (CAI) in medical education is viewed as one of the newer revolutions in medical education, although, in reality, its origins go back a long way and its impact has been gradual but unrelenting. One of the areas in which CAI is being embraced with particular gusto concerns the replacement by virtual microscopy of the traditional use of microscopes and glass slides in the teaching of histology and pathology. The increasing sophistication of the technology (both hardware and software) has enabled the technique to reproduce the experience of microscopy using virtual slides and virtual microscopy in a manner that moves it closer to the experience of actual microscopy. As with most ‘innovations’ in medical education, assessment of its impact has trailed behind its implementation. One of the few really well controlled research studies comparing the impact of the use of real microscopy and virtual microscopy in teaching and testing has, not surprisingly, shown that the tools we use really make little difference in the typical education outcomes that we measure. In such a circumstance, is there any reason to be concerned about the eagerness with which CAI is being embraced in medical education? Perhaps yes. For many medical educators, it has long been apparent that it is not educational tools that make a difference, but, rather, the education professionals who wield those tools. Ludmerer put it well when he said: ‘Teachers are more important than courses. Students should meet the best instructors and be exposed to them for significant periods of time.’ Whether it is an unintended consequence or not, it appears that the increased use of CAI has been accompanied by a decrease in the actual numbers of quality contact hours maintained between medical students and the skilled and experienced MD and PhD education professionals who staff our medical schools. This has been documented in the use of virtual microscopy in the teaching of medical histology. Although this loss of contact time may turn out not to be correlated with declines in examination scores, course grades or even US Medical Licensing Examination Step 1 scores, there is perhaps an invisible manner in which our students’ medical educations will suffer in ways that can only become apparent in the quality of the medical care they will go on to deliver as practising doctors. This form of the ‘hidden curriculum’ relies on the experienced medical educator to assist our students to integrate huge bodies of information, prioritise the importance of various topics, interpret complex visual information, utilise their basic science knowledge during clinical experiences, and to inculcate ethics, professionalism, empathy and communication skills in ways that computer programs will never be able to accomplish. These very benefits that derive from retaining medical educators in medical education are the things we have always had the most difficulty assessing. Although it is possible to infuse our medical curriculum with CAI without reducing the amount of contact time between students and medical education professionals, it takes a high level of vigilance and even a certain amount of sacrifice on the part of institutional administrators and money managers, who cannot be totally faulted for seeing the advent of CAI as an opportunity to reduce scheduled hours of faculty-based instruction (particularly for labour-intensive small-group instruction, including laboratory instruction), in order to shift the balance in the allocation of limited faculty resources towards the other missions of academic medical centres (research and clinical care delivery), where there is a more linear relationship between the amount of faculty time invested and the income generated. In any event, more and better medical education research is needed to Department of Cell Biology, University of Virginia School of Medicine, Charlottesville, Virginia, USA