Technology in Medical Education—Osler Meets Watson

Over the past 20 years, new technologies have changed the experience of practicing medicine at a breakneck pace. A growing number of physicians now use an electronic health record, transmit e-prescriptions, access clinical references on a smartphone, and complete continuing medical education (CME) online. Similarly, today’s millennial-generation medical students are digital natives who inhabit a milieu of online connectivity that renders them unique from prior generations of students. Textbooks have become electronic and lectures are moving online, yet the ultimate goal of medical training is no different today than it was 100 years ago: to prepare future physicians to be effective communicators, diagnosticians and healers as embodied by the great William Osler. Recently, there has been much enthusiasm for utilizing novel technology in medical education. Yale School of Medicine gives each first-year medical student an iPad for personal use. Numerous schools videotape lectures and make them available for streaming online by students, and a few are even experimenting with massive open online courses (MOOCs) in which content is available globally. For example, the University of California-San Francisco now offers CME credit for select online courses offered in partnership with Coursera. Yet, while such innovations may be convenient for learners, in essence they represent replacing one educational process with another, without necessarily altering the educational output itself. We welcome the opportunity to use technology to enhance medical education, but hope to see technology used not as a replacement for other learning tools, but actually as a means to improving the educational process such that students gain additional skills that will benefit them in their clinical practice as physicians. While medical school leaders have begun to show interest in changing the old models of training, many of the most innovative ideas have come from outside of academia. Businessman and innovator Vinod Khosla has provocatively claimed that 80 % of what physicians do could be replaced by computers—thus urging medical students to learn computing and data analytics to enhance their diagnostic and management skills.1 Apple’s App Store contains hundreds of medical education applications to supplement the traditional medical school curriculum, many which were developed by medical students themselves. Even IBM has entered the medical education space by using an iterative learning process to train the Watson supercomputer to become a powerful diagnostician. Yet technology itself is no panacea, and some fear that by rushing to embrace iPhone heart monitors and online learning, medical students may be losing sight of humanism in medicine. Certainly human physicians could never compete with a computer in raw memory or analytical power. But clinical reasoning and empathy remain as much art as science. Take electronic health records (EHRs), for example: some studies show that medical trainees spend more time typing on a computer than they do talking with patients.2 Overcoming this tendency is often hindered by the hidden curriculum, which can reward students who efficiently navigate the EHR and quickly look up data on smartphones during rounds over those who demonstrate compassion through more time-intensive patient interactions. While some may yearn for a bygone era when physicians carried a black bag from house to house, and patient notes were kept mainly inside a physician’s head, we must accept the reality that technology in medicine is here to stay. However, as an educational tool, we believe that technology must be utilized in a manner that helps medical students develop into high-functioning communicators, collaborators, problem-solvers, and team players. Furthermore, clinician-educators must model the effective use of technology such that it ultimately strengthens the patient–doctor relationship so fundamental to the practice of medicine. Building upon these principles, we propose the following components necessary for successful technological innovation in medical education. First, any innovation in technology must be integrated with innovation in pedagogy. For example, the One Laptop per Child Program was touted as an opportunity to transform education in the developing world—yet recent evaluation of the program showed it succeeded in increasing the ratio of computers to pupils but did nothing to improve basic math or language skills amongst students.3 Similarly, giving medical students tablet computers and putting learning material online may be novel, but there is no reason to expect learners to emerge any better off solely due to high technology. On the other hand, when implemented as part of a larger educational redesign, online lectures and interactive modules can free up time during the school day for collaborative learning sessions in the classroom and the clinic.4 The first-year curriculum at the Duke-NUS medical school in Singapore condenses preclinical science into one year, during which students engage in team-based learning exercises and faculty move from lecturers to learning guides and facilitators. Class time is spent discussing, debating, and clarifying material that students have learned outside of lecture halls, resulting in students achieving a deeper understanding of the fundamentals of preclinical science. Second, just as technology is enabling an era of personalized medicine, it can enable an era of personalized medical education. Beyond a basic core curriculum, educational content can be customized to differentiate by pace and mode (e.g., visual versus aural) of learning and to expedite in-depth study of chosen fields. For example, the New York University (NYU) School of Medicine is developing a three-year, individualized curriculum grounded in population health, care coordination, and quality improvement. Students will maintain a virtual patient panel containing de-identified data from NYU Langone Medical Center physician practices. In such a system, educational objectives can be assessed via a dashboard that tracks competency development. At NYU, each student has an ePortfolio which automatically integrates performance across computer-based exams, simulation center sessions, clinical evaluations, and patient logs—thereby enabling students and their mentors to address personal educational progress. Third, today’s learners are wired differently from students of prior generations. A report from the Kaiser Family Foundation found that in 2009, children aged 8–18 spent an average of over 7 h each day using media (TV, music, computer, video games, movies), but actually consumed nearly 11 h of media daily, due to the fact that 29 % of their time was spent multitasking with multiple sources of media.5 Further, the percentage of time spent with print media represented only 6 % of all media exposure. Raised in this plugged-in, multimedia environment, today’s medical students demand more than static textbooks and non-interactive lecture formats for learning. Medical schools trying to engage these students by putting lectures and curricular materials online may not succeed in meeting the learning needs of this generation of multi-taskers. Instead, technology can be put to better use through more interactive online curricula, as well as through in-person simulation labs. Furthermore, social media offers opportunities for both students and educators to share ideas and work collaboratively. A recent pilot at Penn State used Twitter, YouTube and blogging in courses on medical writing and dementia care.6 In addition, the hashtag #meded is used by a large community of medical educators on Twitter who post about educational research and medical curricula, and the weekly MedEd Twitter chat allows educators to discuss medical education in a virtual space. Finally, we need to rigorously assess technological interventions and innovation in medical education—just as we assess novel therapeutic agents—by instituting a large-scale consortium of schools that could collaborate in educational experimentation and outcome measurement. Eventually, educational curricula deemed most successful can be implemented on a national (and international) scale—just as drug therapies that show promise in Phase III trials are distributed globally. Didactic resources demonstrated to be most effective could be pooled as a “21st century Harrison’s”—with potential cost savings resulting from this sharing of teaching responsibility. The Accelerating Change in Medical Education program, a learning collaborative of 11 medical schools funded by the American Medical Association, could form the nucleus of a broader effort. Ultimately, technology must help expose and immerse learners in the rapid changes occurring in health care delivery. Medical education must not occur in an ivory tower, and technology should not be used to further distance trainees from the front lines of health care. Focusing educational reform only on moving traditional classroom activities online runs the risk of students and physicians spending even more time typing away on a keyboard—out of sight of a patient. On the other hand, thoughtful use of technology can enable future physicians to utilize Watson in order to better practice medicine in the spirit of Osler.